Forty-three cases of hepatitis C infection nationwide — including five in Maryland — have been attributed to transmission by Kwiatkowski, the report said. The five are among approximately 1,700 people who faced potential exposure because they had procedures at four Maryland hospitals in which Kwiatkowski was involved.
Between 2008 and 2010, Kwiatkowski worked at the Baltimore VA Medical Center, Johns Hopkins Hospital, Maryland General Hospital and MedStar Southern Maryland Hospital Center.
He has pleaded not guilty to federal drug charges and is in jail awaiting trial.
The report said the resulting hepatitis C outbreak occurred because of regulatory failures, weak licensing and credentialing procedures, and management lapses at hospitals. The staffing agencies that found temporary work for him are largely unregulated, creating risks for patients, the report said.
In one instance, a staffing agency found him a job with the University of Pittsburgh Medical CenterPresbyterian. A co-worker allegedly observed him putting a fentanyl syringe down his scrub pants; he tested positive for fentanyl, a narcotic, and was terminated. After it conducted its own drug test of Kwiatkowski, the staffing agency determined that the allegations were unsubstantiated.
Six months later, the agency placed him at MedStar Southern Maryland Hospital, where he was eventually terminated for forgery and falsifying time records, the report said.
When he applied for a radiographer license with the Maryland Board of Physicians, Kwiatkowski lied about his employment suspensions and terminations, the report said. Because of that, the board analyst reviewing his application did not know of his termination by the University of Pittsburgh Medical Center or a suspension by the University of Michigan Hospital.
Kwiatkowski also did not tell the board that he had been sentenced to six months of probation and fined $1,075 in 2005 after pleading guilty to a charge of driving while intoxicated.
The board, which did not conduct a criminal background check, issued him a radiographer license in October 2008.
When he applied to renew it the following June, he again lied about previous suspensions and terminations and did not disclose that he had been recently terminated by MedStar Southern Maryland Hospital. The board reissued his license in July 2009.
The report recommended that the board revise its procedures for licensing health professionals and include a national criminal background check.
The report also faulted hospitals for not sharing information about health-care workers who may pose a safety risk to patients.
During his work in Pennsylvania, Maryland and Arizona, “there were clear indications that Mr. Kwiatkowski was diverting fentanyl and engaging in other behaviors that posed risks to patients,” the report said. “Yet Maryland hospitals were not made aware of what occurred in Pennsylvania, the Arizona hospital was not made aware of what occurred in Pennsylvania and Maryland, and hospitals in Kansas and New Hampshire were not made aware of what occurred in Arizona, Maryland or Pennsylvania.”