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A rash of bloodstream infections at a cancer center spurred clinicians to turn into amateur sleuths, which in turn revealed that a former nurse had allegedly caused the outbreak by replacing intravenous painkiller medication with tap water.

Federal charges were file against Kelsey Mulvey, 27, who faces 10 years in prison and a $250,000 fine for allegedly obtaining controlled substances by fraud, tampering, and a violation of the Health Insurance Portability and Accountability Act (HIPAA).

The clinicians shared their experience in a letter to the New England Journal of Medicine in the hopes that it would help other medical professionals with similar cases.

An article on Medpage Today detailed the circumstances of the case, which began in June of 2018 at the Roswell Park Comprehensive Cancer Center in Buffalo, New York.

Six patients developed bloodstream infections from sphingomonas paucimobilis, a bacterium found in soil and drinking water that can take root in distilled water tanks, respirators and dialysis machines. Patients with chronic conditions are particularly susceptible to it, and infection can result in sepsis, peritonitis and pulmonary embolisms.

However, the bacteria rarely causes bloodstream infections, which drew the attention of Jillianna Wasiura, RN, Brahm Segal, MD and Katherine Mullin, MD, all clinicians at the Roswell Park facility. They checked a number of possible sources, including regional microbiology labs and pharmaceutical vendors, before finding the source of the bacteria: compounded syringes with the prescription opioid painkiller hydromorphone.

Four of seven syringes stored in a Pyxis MedStation, an automated medication-dispensing system, tested positive for sphingomonas, as well as other waterborne bacteria. Further analysis revealed that the syringes had been diluted with tap water from a single source, which contaminated the medication.

A criminal complaint led to an investigation by federal agents, including representatives from the Food and Drug Administration, the Federal Bureau of Investigation, and the New York State Attorney General’s Office.

In a statement issued by the U.S. Attorney’s Office for the Western District of New York, former Roswell Park nurse Kelsey Mulvey was charged with removing the medication from the Pyxis machine, which she had access to through her position at the center.

According to the statement, Mulvey not only removed the hydromorphone syringes, but also methadone, oxycodone, and lorazepam. The center became suspicious of Mulvey’s actions in June of 2018 when a large number of transactions on the Pyxis machines registered as “cancelled removed,” which meant that the machine drawer with certain medications was accessed but the transaction was subsequently cancelled.

The statement also alleged that Mulvey removed medication from floors and wings of the center where she did not have patients, and accessed them during her regular shifts as well as on her days off and three days of scheduled vacation. Mulvey resigned from the center on July 13, 2018 to avoid termination. Though charged with the aforementioned violations, Mulvey is presumed innocent until, and unless, proven guilty.

As Medpage noted, none of the six patients died as a result of the infections, though two subsequently passed away as a result of the cancers.

U.S. Attorney James P. Kennedy Jr. alluded in the statement to the “destructive power of opioid addiction,” which appeared to suggest that Mulvey’s actions were motivated by drug dependency.

“In this case, however, the harm caused by the defendant’s actions resulted in not only harm to herself but in harm to some of the most compromised and vulnerable individuals in our community—those members of our community receiving cancer treatments.”