Former Radiology Technician David Kwiatkowski, 33, gave little if any thought to the patients he put in grave danger when he injected himself with the powerful opiate fentanyl and then replaced the syringe contents with saline, knowing that the Hepatitis C he carried had a very good chance of being passed on via the dirty needle he left for use in unsuspecting patients turned victims. But then again neither did the Arizona Heart Hospital, the Arizona Radiation Regulatory Agency (ARRA) or the American Registry of Radiologic Technologists.
Kwiatkowski, born in Michigan, was fired from the Arizona Heart Hospital (AHH) in 2010 after a fellow employee found him passed out in a bathroom with a syringe marked “fentanyl” and needle floating in the toilet. AHH says Kwiatkowski was immediately fired, and that he relinquished his license as a radiologic technologist in AZ. A search of the AZ Medical Radiologic Technology Board of Examiners, a division of the AARA, shows Kwiatkowski’s license being REVOKED as of 7/31/2010. Law Med has found no evidence that the AHH reported Kwiatkowski to the national American Registry of Radiologic Technologists. Whether they did or not we cannot say for sure.
The director of the AZ AARA says officials ‘stopped their investigation’ when Kwiatkowski moved out of state, which apparently happened within days of being fired. “We had no jurisdiction,” claims AARA’s Aubrey Godwin. “If drugs or alcohol were involved, we would want to get blood tests done, but he was out of state, so it was sort of hard to implement.” Law Med would point out that either Aubrey Godwin has absolutely no idea what he is talking about, or he is passing the buck. The fact of the matter is ONLY the AZ AARA has jurisdiction to conduct an investigation of one of their certification holders for incidents which occurred in AZ under Title 32 Professions and Occupations §28 Article 3 Regulation 21- Revocation or suspension of certificate; other disciplines; grounds; procedures; penalty; judicial review.
It is also rather difficult to believe that Kwiatkowski, who was found unconscious in the bathroom of a sophisticated specialty hospital complete with an emergency room, was not immediately provided advanced emergency care which would include toxicology blood testing. Regardless, representations that because someone flees the state and a blood sample cannot be obtained, investigation into the misconduct of a health care professional must/should be abandoned is simply absurd.
But officials in AZ can’t shoulder all the blame. According to a lawsuit filed against the agency that placed Kwiatkowski in the hospitals where he worked, Kwaitkowski was discovered diverting drugs as early as 2008, and his drug use was allegedly confirmed by blood tests.
Since the AARA’s Medical Radiologic Technology Board of Examiners revoked Kwiatkowski’s certification in AZ, the Board had to have done SOME amount of investigating since state statutes spell out the process which must be followed prior to revocation. It is worth noting that state nursing and medical boards do not end investigations if a nurse or physician moves out of state. If it is true that the AZ MRTBE does, this would greatly diminish the usefulness of the board. In the past RNs and MDs around the country COULD move state to state after having action taken against their license, or investigations begun in any particular state. Not so anymore since these state boards communicate with each other and a revocation in one state will almost always result in the revocation of licenses held in all other states also. Another safeguard is the National Practitioner Data Bank (NPDB). By law AZ MRTBE was REQUIRED to report the revocation of Kwiatkowski’s certification to the NPDB. Had they done so all prospective future employers in any state would be able to instantly discover that AZ had taken action against Kwiatkowski, and why. It is also not clear whether the AHH or the MRTBE reported Kwiatkowski to the NPDB as required by law.
Kwiatkowski was a “traveling” technician placed at the AHH by a staffing company, Springboard, Inc., who says they immediately reported Kwiatkowski to the American Registry of Radiologic Technologists (ARRT) according to a Springboard spokesman.The AART registers and certifies Radiological Technicians. ARRT uses “certification” to describe the one-time awarding of a certificate after an individual satisfies all eligibility requirements including the AART certification exam. “Registration” is the annual renewal of the certificate’s validity and allows us of the title Registered Technician (R.T.), and AART certification/registration has become recognized as the gold standard for determining qualifications of these professionals. Certification by the AART is also predicated on adherence to their “Standards of Ethics” which the AART enforces through their Ethic Committee which investigates complaints and takes action against their Certified and Registered technicians, including revocation of certification. Employers and states rely heavily on the AART Certification status of a prospective radiological technician in determining qualifications and eligibility.
Thirty-seven states utilize ARRT-administered exams for state licensing/certification purposes in fact. BUT AT LEAST 11 STATES HAVE ABSOLUTELY NO REQUIREMENTS FOR EDUCATION/LICENSING/CERTIFICATION OF RADIOLOGICAL TECHNICIANS, AT ALL. That’s right, in these states ANYONE, and I mean anyone at all, can be employed as an X-ray technician in a hospital, clinic, physicians office etc. The guy that mows your lawn can legally take your chest x-ray or perform other radiological exams, like CT Scans in nearly 1/4 of states. Should the techs in these states be fired for harming patients or stealing drugs there is absolutely NO regulatory body that can prevent them from moving to another such state to continue in a similar position. In fact absent a report to the NPDB (which can only be made when action is taken against a state issued license) and/or public action against an individuals AART Certification, by the AART, a technician has little risk of not being able to obtain a license/certification/work in another state once one state revokes their state certification/license. Individuals working in states which do not require licensure/certification cannot be reported to any responsible body and no action can ever be taken against them unless brought by law enforcement subsequent to criminal charges.
However the AART failed to take any action and Kwiatkowski was on the job at Temple University Hospital in Pennsylvania within weeks of being fired in AZ, and then went on to work in Kansas and Georgia before working in New Hampshire in 2011. He had also previously worked in hospitals in the states of Maryland, Michigan, New York.
Exactly how Kwiatkowski was discovered diverting drugs at the Exeter Hospital and when remains unclear. On July 21, 2012 Kwiatkowski was arrested in Massachusetts presumably after relocating there after being fired by Exeter. It is noteworthy that only after the arrest did the AART act to revoke Kwiatkowski’s certification. A credential verification search on their website shows the following results:
Not Registered REVOKED as of 09/2012 Based upon evidence provided to the Ethics Committee, ARRT has revoked the certification and registration of this individual.
From CBS News Crimesider:
David Kwiatkowski, a traveling hospital technician accused of infecting dozens of patients with hepatitis C through tainted needles, told investigators he had been stealing drugs for more than a decade and was “killing a lot of people,” according to a plea agreement filed Monday that would send him to prison for 30 to 40 years.
Kwiatkowski, who has been jailed since his arrest in July 2012, is accused of stealing painkiller syringes from Exeter Hospital’s cardiac catheterization lab and replacing them with saline tainted with his blood. He has agreed to plead guilty to the 14 federal drug theft and tampering charges he faced in exchange for a lighter sentence. Had he been convicted at trial, he could have been sentenced to up to 98 years behind bars.
Thirty-two patients in New Hampshire have been diagnosed with the strain of hepatitis C carried by Kwiatkowski, who worked at 18 hospitals in seven states before being hired in New Hampshire in 2011. There have been seven cases in Maryland, six in Kansas and one in Pennsylvania. One of the Kansas patients has died, and hepatitis C, a blood-borne viral infection that can cause liver disease and chronic health issues, played a “contributing role,” the plea agreement said.
Despite one of the victims dying, Kwiatkowski was not charged with murder, likely, as prosecutors said, because Hepatitis C was found to play a “contributing role” and a direct cause of the death could not be established. Unless the plea agreement stipulates otherwise however, prosecutors would be free to charge Kwiatkowski with murder should any of his victims die directly from their Hepatitis C in the future. We recently saw a successful 2nd degree murder conviction in the case of Dr. Dipak Desai where prosecutors argued he was responsible for transmission of Hepatitis C to a patient who died from the disease. According to the plea agreement, Kwiatkowski told an investigator, “I’m going to kill a lot of people out of this.”
“The defendant admitted that he diverted drugs in a similar way at Houston Medical Center in Georgia and Hays Medical Center in Kansas,” the plea agreement states. “He estimated that he swapped syringes at least 20 times in Kansas and approximately 30 times in Georgia. But if a New Hampshire court accepts Kwiatkowski’s plea deal, he can avoid federal criminal charges in Kansas, Maryland and Georgia, the plea agreement goes on to say.
According to state and hospital officials, he worked in as a radiology technician and in cardiac catheterization labs in the following locations, but this list is not complete:
– Oakwood Annapolis Hospital in Wayne, Michigan, January to September 2007;
– Saint Francis Hospital, Poughkeepsie, New York, November 2007 to February 2008;
– UPMC Presbyterian, Pittsburgh, March 2008 to May 2008;
– Baltimore Veterans Affairs Medical Center, May 2008 to November 2008;
– Southern Maryland Hospital, Clinton, Maryland, December 2008 to February 2009;
– Johns Hopkins Hospital, Baltimore, July 2009 to January 2010;
– Maryland General Hospital, Baltimore, January 2010 to March 2010;
– Temple University Hospital, Philadelphia, April 2010;
– Hays Medical Center, Hays, Kansas, May 2010 to September 2010;
– Houston Medical Center, Warner Robins, Georgia, October 2010 to March 2011.
– Exeter Hospital, Concord, New Hampshire, 2011
For more on where Kwiatkowski may have worked and important details about the case read HERE.
US Attorney’s Press Release when Kwiatkowski was indicted:kwiatkowski, dipak desai, National Practitioner Data Bank, hepatitis c, defendant, plea agreement