In May 2012, Exeter Hospital in Exeter, New Hampshire, announced it would temporarily close its cardiac catheterization lab after dozens of patients were diagnosed with acute hepatitis C infection.
In time, a multi-state investigation revealed that every case was linked back to a lab technician who was using patient drugs himself, and then putting contaminated vials back into use.
Further, there were multiple opportunities for the hospitals in which this technician worked to protect patients from him - but none were taken.
In a new article, ethicist Bill Nelson and I propose a nationwide reporting system that would help protect patients from the risks of drug diversion-related outbreaks like this one.