A nurse in New York allegedly stole injectable opioids for her own use, then refilled hospital syringes with tap water in a move that caused rare infections in cancer patients, according to a new report. The report published Thursday in the New England Journal of Medicine notes six cancer patients developed bloodstream infections at Buffalo's Roswell Park Comprehensive Cancer Center over June and July of 2018. All six were infected with Sphingomonas paucimobilis, a soil and water bacterium that usually surfaces at the hospital in only one or two cases per year, reports Medscape. Investigators who eventually found the same bacterium in hospital syringes containing the opioid hydromorphone concluded the nurse had "repetitively and inappropriately" accessed a locked drawer, removed the narcotic from the syringes, and replaced it "with an equal volume of tap water," per Live Science.
"We share our experience to alert health care providers that, in this age of profound prevalence of opioid addiction, drug diversion is an important consideration when a cluster of waterborne bacteremia is identified," the report notes. It doesn't identify the culprit. However, Live Science reports a former nurse at the cancer center—which installed video monitoring systems after notifying the public of the breach last fall—has been charged with stealing pain medications. According to a criminal complaint, Kelsey Mulvey is accused of failing to properly administer medications, not just to six cancer patients, but to 81 between February and June of 2018. The complaint claims Mulvey tampered with vials of medication, including hydromorphone, even on days she wasn't scheduled to work and in areas where she wasn't treating patients. She faces up to 10 years in prison and a $250,000 fine if convicted. (Read more opioids stories.)