Supervisors at a Maryland hospital weren't surprised when drugs were missing from a treatment room where contract radiology technician David Kwiatkowski was assigned.
A manager had spotted him going through needle-disposal containers and he was among three employees under suspicion for taking vials of the narcotic fentanyl from the cardiac catheter lab, a state investigation found.
But when a staffing agency later contacted the hospital about Kwiatkowski, a manager gave him a satisfactory review, writing: "David is very professional and worked very hard."
The incident at the Maryland facility, detailed in a state report released Wednesday, was just one example of what health officials called a systemwide breakdown that allowed Kwiatkowski to inject himself with stolen narcotics-filled syringes.
The technician, who was infected with
In December, Kwiatkowski pleaded not guilty to federal charges that included tampering with a consumer product and obtaining controlled substances by fraud. His trial is scheduled for October.
"I think that there were missed opportunities that could have stopped Mr. Kwiatkowski from diverting drugs in Maryland," said Dr. Lucy Wilson, chief of the state health department's epidemiology center, who helped investigate Kwiatkowski's actions during the time he worked at four Maryland hospitals from 2008 to 2010.
The report by the Maryland Department of Health and Mental Hygiene for the first time details Kwiatkowski's time working in the state.
For years, Kwiatkowski continued working at hospitals, despite being investigated by other facilities for allegedly stealing and using drugs. Kwiatkowksi often quit the jobs before investigations were completed, and the hospitals and staffing agencies often didn't pass on information to his new employers, according to the report.
The state investigation found gaps in the health care system, including problems in the way that staffing agencies screen applicants and a culture at hospitals that makes staff wary of reporting bad employees.
Government regulators also failed, not sufficiently verifying worker backgrounds and relying on applicants to self-report criminal history. Kwiatkowski failed to disclose a DWI arrest and other disciplinary actions that might have raised warning signs, the state report found. A national registry meant to flag problem workers did not list all of Kwiatkowski's transgressions.
"We found there wasn't one single overarching issue, but really it was instead multiple systemwide vulnerabilities in multiple arenas," Wilson said.
Kwiatkowski first started working in Maryland at the Baltimore
He first applied for a radiographer license with the Maryland Board of Physicians on Sept. 25, 2008, but failed to disclose suspensions and other terminations, the state report said.
He told the board about a 2001 DUI arrest, but not a 2005 DWI in Michigan, where he was sentenced to six months of probation. He didn't divulge that he quit a job at the University of Michigan Hospital after it suspended him in December 2006 because officials suspected he was stealing drugs, the report found.
In May 2008, a staffing company owned by Maxim Healthcare Services terminated Kwiatkowski's contract with the University of Pittsburgh Medical Center after he was caught with fentanyl syringes in his scrub pants and tested positive for narcotics. However, Columbia-based Maxim continued to place Kwiatkowksi in jobs in Maryland, and the technician failed to tell Maryland officials about that incident, the report said.
Analysts with the Board of Physicians only contact past employers that applicants list, so they did not know to call the Michigan or Pittsburgh hospitals, the state report said. The board doesn't do background checks, so it would not have caught any criminal history. Kwiatkowski was awarded a license that October.
Maxim assigned Kwiatkowski to Southern Maryland Hospital in Clinton on Nov. 9, 2008, to work in its
When Kwiatkowski filed to renew his Maryland application in June, he again failed to list suspensions and terminations, including the Southern Maryland Hospital incident, according to the state report. Maryland issued him a new license.
Kwiatkowski continued to work in Maryland for several more weeks, first at
As part of the report, state health officials outline several recommendations for improving the way temporary workers are regulated in Maryland. Legislation pending before the General Assembly would require that health care staffing agencies be licensed. Currently, only nursing staffing agencies are regulated.
The report cites Maxim specifically for failing to divulge problems with Kwiatkowski. The report said Maxim acknowledged fabricating an email that appeared to come from the Maryland Board of Physicians in 2009, saying the board had received notification from Maxim about unprofessional conduct by Kwiatkowski.
Maxim declined to comment about details of the report, but said it is cooperating with any investigation.
"We have reviewed the department's report and take their recommendations seriously," the company said in an email. "We do, however, believe that certain representations in the report regarding our company require additional detail and clarification. Given its breadth, we are continuing to review the report in greater detail and will follow up with the state directly."
The report also recommended that the Board of Physicians augment its licensing of contract health workers with background checks and better verification processes.
"We have spent the last year making many improvements in our operations," said Carole Catalfo, the board's executive director. "We will certainly take time to carefully review and discuss the report and its recommendations.
Kwiatkowski was able to continue practicing because many co-workers, as well as staffing agencies and hospital supervisors, failed to report concerns about his conduct. The report said many feared being sued if they turned in a fellow worker.
State officials recommended legislation that would expand immunity laws to health care workers.
The report also called for standardizing drug-diversion programs at hospitals and recommended that the federal government expand its national data bank to include more information about contract health workers.
Local hospitals say they have many safeguards in place, but welcome other ways to improve the system.
"We embrace any ideas that help ensure public safety, and we look forward to working together to prevent something like this from ever happening again," a Johns Hopkins spokeswoman said in a statement.
Jim Reiter, a spokesman for the Maryland Hospital Association, said hospitals have checks and balances in place, but on rare occasions determined individuals will find loopholes.
"When you have the assumption that somebody has been cleared and certified by the board and an agency, there is no reason to believe they are not going to do what they're supposed to do," he said.