Report includes recommendations for strengthening legal and regulatory protections

Baltimore (March 20, 2013) – The Maryland Department of Health and Mental Hygiene today released the results of its review of the employment of David Kwiatkowski in Maryland hospitals, with recommendations for strengthening legal and regulatory protections in the areas of drug diversion, infection control and hiring and managing of health care workers

In July 2012, Mr. Kwiatkowski was arrested on suspicion of unlawful drug diversion activity that transmitted the hepatitis C infection to patients at a New Hampshire hospital.  Mr. Kwiatkowski had been employed as a radiographer by multiple temporary staffing agencies and had worked in several states, including Maryland, where he is now suspected of narcotic drug diversion and resultant hepatitis C transmission.

In Maryland, Mr. Kwiatkowski was temporarily employed from 2008 through 2010 at four hospitals. Over 1700 patients at these hospitals have been notified of potential exposure to the hepatitis C virus via Mr. Kwiatkowski. To date, there have been five documented cases of hepatitis C infection among those notified; the five cases involve patients at two of the four Maryland hospitals where Mr. Kwiatkowski worked.

A review team at DHMH conducted a comprehensive assessment of Mr. Kwiatkowski’s employment as a healthcare worker in Maryland.  The resulting report finds that this hepatitis C outbreak did not result from a single critical gap or deficiency, but was, instead, the result of multiple gaps in regulations, allied health professional credentialing and licensing procedures, and human resources and risk management practices at staffing agencies and facilities.

The report makes findings and recommendations in five areas:

  • Licensing and regulatory oversight of staffing agencies.  The report finds, “Interstate staffing agencies that place allied health professionals, like those that found employment for Mr. Kwiatkowski, are largely unregulated nationwide, creating risks for patients.”  The report recommends expanding existing state regulations of nurse staffing agencies to include regulation of staffing agencies that place any healthcare practitioner. Legislation to accomplish this goal, SB 1057 and HB 1529, is now pending in the Maryland legislature.
  • Licensing of allied health professionals.  The report finds that Mr. Kwiatkowski “falsely obtained and renewed his radiographer certification from the American Registry of Radiologic Technologists, and his license from the Maryland Board of Physicians.”  The report recommends that the Board of Physicians review and revise its procedures for licensing allied health professionals.
  • Employment references. The report finds, “Many healthcare co-workers, facilities and staffing agencies failed to report concerns about Mr. Kwiatkowski’s conduct, including concerns about drug diversion, to licensing boards and to other employers during reference checks.”  The report recommends consideration of specific legislation related to disclosure of negative employment references and protective immunity in health care.
  • Prevention of drug diversion. The report finds, “Many hospitals have drug diversion monitoring programs.  Such programs, however, are not currently mandated or standardized, and the scope and efficacy of existing programs varies among facilities.”  The report recommends that hospitals and other healthcare facilities develop processes to prevent and respond to drug diversion, including identifying and referring individuals at risk for treatment.

Interstate reporting. The report finds, “There are limitations on the usefulness of the [federal] Data Bank for addressing ongoing misconduct by allied health professionals.”  The report recommends that the federal government expand the Data Bank (a national provider registry) to capture additional information about allied health professionals who may pose risks to patient safety, especially those who work in multiple statees.

The full report can be found at