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Presentation for Alabama Hospital Association. Objectives 1.To familiarize Hospital Association Personnel with federal criminal violations that they may.

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Presentation on theme: "Presentation for Alabama Hospital Association. Objectives 1.To familiarize Hospital Association Personnel with federal criminal violations that they may."— Presentation transcript:

1 Presentation for Alabama Hospital Association

2 Objectives 1.To familiarize Hospital Association Personnel with federal criminal violations that they may encounter. 2.To encourage Hospital Association Personnel and their delegates to report these violations to FDA/OCI (ASAP).

3 FDA/ Office of Criminal Investigations OCI was established in OCI was established in The Office of Criminal Investigations currently operates out of 29 offices throughout the United States. The Office of Criminal Investigations currently operates out of 29 offices throughout the United States. There are approximately 180 Special Agents hired from other traditional law enforcement agencies. There are approximately 180 Special Agents hired from other traditional law enforcement agencies.

4 Office of Criminal Investigations OCI is the criminal investigative arm of the FDA. OCI is the criminal investigative arm of the FDA. OCI is a traditional Federal Criminal Investigative Agency. OCI is a traditional Federal Criminal Investigative Agency. OCI does not conduct inspections or conduct typical regulatory functions. OCI does not conduct inspections or conduct typical regulatory functions. FDA Investigators (Consumer Safety Officers) and Inspectors conduct regulatory inspections; OCI Special Agents have full federal law enforcement authority, conduct criminal investigations and present cases to the U.S. Attorney’s Office for federal prosecution. FDA Investigators (Consumer Safety Officers) and Inspectors conduct regulatory inspections; OCI Special Agents have full federal law enforcement authority, conduct criminal investigations and present cases to the U.S. Attorney’s Office for federal prosecution.

5 Boston New York Metro Washington OCI Headquarters Atlanta Miami Austin Kansas City Chicago Los Angeles San Francisco OCI Field and Resident Offices. Houston San Juan Nashville Buffalo Headquarters Field Offices Resident Offices Domicile Offices New Orleans Seattle Denver Phoenix Minneapolis Dallas Tampa Philadelphia San Antonio Norfolk Syracuse Cincinnati Birmingham Raleigh Detroit

6 General Areas of Enforcement Manufacturing and Distribution of counterfeit and unapproved drugs  Manufacturing and Distribution of counterfeit and unapproved drugs Illicit prescription drug diversion (DEA vs. FDA/OCI)  Illicit prescription drug diversion (DEA vs. FDA/OCI) Product substitution crimes  Product substitution crimes  Product Tampering  Schemes involving fraudulent health treatments New drug application fraud  New drug application fraud Frauds involving FDA regulated products  Frauds involving FDA regulated products Fraud associated with clinical investigations  Fraud associated with clinical investigations

7 OCI Federal Law Enforcement Agencies U.S. Attorney’s State/Local Law Enforcement Agencies U.S. Intelligence Community Private Industry FDA Foreign Law Enforcement Agencies Federal/State Health Authorities

8 Federal Anti-Tampering Act 18 USC 1365(a)-Whoever, with reckless disregard for the risk that another person will be placed in danger of death or bodily injury and under circumstances manifesting extreme indifference to such risk, tampers with any consumer product that affects interstate or foreign commerce, or the labeling of, or container for, any such product, or attempts to do so, commits product tampering.

9 Federal Anti-Tampering Act 1.Food, drugs, medical devices, cosmetics, biologics (such as blood) are all considered to be consumer products. 2.It is not necessary that death or bodily injury occur. 3. It is not necessary to prove that the suspect intended to cause death or bodily injury. 4. All that is required is, as a result of the tampering, death or any bodily injury could have happened. 5. Bodily injury is any physical or mental injury, however slight, no matter how temporary.

10 Federal Anti-Tampering Act Definition of Bodily Injury (18 USC 1365(h)(4)) A cut, abrasion, bruise, burn, or disfigurement. Physical pain. Illness. Impairment of the function of a bodily member, organ, or mental faculty. Any other injury to the body, no matter how temporary.

11 Federal Anti-Tampering Act Additional charges within the statute 18 USC §1365(b) – intent to cause serious injury the business of any person, taints any consumer product… 18 USC §1365(c) – knowingly communicates false information that a consumer product has been tainted,…,and if such tainting, had it occurred, would create a risk of death or bodily jury to another person… 18 USC §1365(d) – knowingly threatens and threat may reasonably be expected to be believed. 18 USC §1365(e) – conspiracy – 2 or more persons tamper or attempt to tamper with a consumer product.

12 Penalties 1.Level 25 (57-71 months) 2.Enhancement for multiple victims. 3.Enhancement for serious bodily injury or death. 4.Special Skill or Position of Trust 5.Maximum penalty is life.

13 Signs of Tampering/Drug Diversion Tampering often referred to as “substitution.” Tampering often referred to as “substitution.” Missing drugs – controlled & non-controlled Missing drugs – controlled & non-controlled Incorrect counts (reconciliation), or not! Incorrect counts (reconciliation), or not! Apparent false record reporting Apparent false record reporting Suspicious behavior by staff member Suspicious behavior by staff member Multiple unjustified or cancelled accesses to automated medicine dispensing (Pyxis) machines Multiple unjustified or cancelled accesses to automated medicine dispensing (Pyxis) machines Visual signs of compromised drug packaging/needles/vials etc. Visual signs of compromised drug packaging/needles/vials etc. Exaggerated claims by staff regarding wasting or loss of drug product. Exaggerated claims by staff regarding wasting or loss of drug product. Records reflect the over-prescribing or the inadequate prescribing of drugs to patients. Records reflect the over-prescribing or the inadequate prescribing of drugs to patients. Increase in patient complaints of pain after receiving pain medication. Increase in patient complaints of pain after receiving pain medication.

14 Signs of Tampering/Drug Diversion Suspect is acting suspicious and may be doing the following: –Taking a great deal of time off or always on-duty or in the hospital when not on-duty –Extended unexplained absences –Extended restroom breaks –Mood swings –Personal life issues –Coming in early, staying late –Always where they shouldn’t be or not where they should be –Dealing with patients who require pain medications –Nervousness, nausea, change in behavior

15 If you suspect tampering Call FDA/OCI immediately Call FDA/OCI immediately –Even if only a mere suspicion – let us do our job and reduce your liability –Don’t wait until someone gets hurt –Collect and segregate evidence – chain of custody – but don’t talk to suspect and don’t conduct a full investigation Press/Discovery Issues Press/Discovery Issues –Why it is better to be a part of the solution instead of being part of the problem

16 Course of Action by FDA/OCI Arrange for interview of MedExec/Hospital Staff or delegate (away from suspect) Arrange for interview of MedExec/Hospital Staff or delegate (away from suspect) Obtain documents and evidence Obtain documents and evidence Initiate investigation Initiate investigation –Surveillance –Interviews –Cameras (non-private areas) –Subpoenas directed towards suspect

17 Review 1.Not every drug theft is a tampering case. Not every tampering case is going to get prosecuted. 2.Must be an adulteration of the product, its container, or its labeling. 3.As a result of the tampering, there must be the risk of death or any bodily injury – just the risk! 4.Take custody of any suspected tampered drug products – minimize handling and maintain chain of custody. Check remaining sources – or ask us to check as soon as possible. 5.Engage OCI as soon as possible. This is a Federal crime – not a state or local police department matter.

18 Concealing Unlawful Activity 1.Telling patients or staff to not tell anyone. 2. Destroying or altering documents to conceal the activity or minimize liability. 3. Lying to any regulatory or law enforcement agency. 4. Withholding information/documents pertinent to the investigation.

19 Preventative Measures to avoid tampering/drug diversion Create Rules/policies and procedures that deter such activity. Create Rules/policies and procedures that deter such activity. Incorporate a “check and balance” system. Incorporate a “check and balance” system. Always have at least two qualified individuals responsible for accountability of the drugs. Always have at least two qualified individuals responsible for accountability of the drugs. Require documentation - Review documentation. Require documentation - Review documentation. Random Audits of both paperwork and physical inventory. Random Audits of both paperwork and physical inventory. Random drug testing-Don’t wait for incident to occur. (Make sure testing facility will provide you with what you expect.) Conduct the “right” tests. Random drug testing-Don’t wait for incident to occur. (Make sure testing facility will provide you with what you expect.) Conduct the “right” tests. Play “devil’s advocate” – look for risks, then eliminate them. Play “devil’s advocate” – look for risks, then eliminate them. Pay attention to your employees and their behavior. Pay attention to your employees and their behavior.

20 Drug Diversion Theft of commercial quantities of drugs for profit. * Controlled vs. non-controlled. * Drugs are resold at a profit to a third party distributor. Diverted for personal use * Discuss need to determine if tampering was an issue. If simple theft, then discuss DEA’S involvement

21 U.S. v Nancy L. Moyer (No /8th Circuit, 1999) FACTS Moyer, a medical doctor, was charged with product tampering (18 USC 1365(a)) after an investigation determined that she had been inserting a needle-syringe into a morphine delivery device in a hospital, removing morphine and replacing it with saline. Moyer was subsequently found guilty and appealed her conviction on several grounds. Moyer, a medical doctor, was charged with product tampering (18 USC 1365(a)) after an investigation determined that she had been inserting a needle-syringe into a morphine delivery device in a hospital, removing morphine and replacing it with saline. Moyer was subsequently found guilty and appealed her conviction on several grounds.

22 U.S. v Nancy L. Moyer (No /8th Circuit, 1999) Issues Moyer argued that the government was required to prove that Moyer performed a malicious act when tampering with a consumer product beyond merely tampering with the product. Moyer argued that the government was required to prove that Moyer performed a malicious act when tampering with a consumer product beyond merely tampering with the product. Moyer argued that her actions did not constitute a reckless disregard of exposing others to the possibility of death or bodily injury and that she did not act with extreme indifference to such risk. Moyer argued that her actions did not constitute a reckless disregard of exposing others to the possibility of death or bodily injury and that she did not act with extreme indifference to such risk. Moyer contended that her tampering with the drug delivery device did not constitute any effect upon interstate commerce. Moyer contended that her tampering with the drug delivery device did not constitute any effect upon interstate commerce. Moyer argued that she did not act with extreme indifference regarding risks to which her tampering exposed her patients to. Moyer argued that she did not act with extreme indifference regarding risks to which her tampering exposed her patients to. Moyer argued that her resulting sentence was too harsh. Moyer argued that her resulting sentence was too harsh.

23 U.S. v Nancy L. Moyer (No /8th Circuit, 1999) Decision The court ruled that there was no requirement for the government to show that Moyer acted maliciously. The court ruled that the term, "tampering," merely describes the physical act of product adulteration. The court ruled that there was no requirement for the government to show that Moyer acted maliciously. The court ruled that the term, "tampering," merely describes the physical act of product adulteration. As a result of Moyer's morphine thefts, her hospital was required to order additional morphine from out-of-state manufacturers. This was sufficient to support a finding that Moyer's tampering had an effect upon interstate commerce. As a result of Moyer's morphine thefts, her hospital was required to order additional morphine from out-of-state manufacturers. This was sufficient to support a finding that Moyer's tampering had an effect upon interstate commerce. Testimony by expert witnesses that Moyer's morphine thefts placed her patients at risk of increased pain, agitation, infection, and air embolism and the defendant, as a physician, was aware at the time of the tampering that her actions could have created health risks for her patients was sufficient to support a jury's finding that Moyer acted with reckless disregard of serious health risks to which her actions exposed her critically ill patients. Testimony by expert witnesses that Moyer's morphine thefts placed her patients at risk of increased pain, agitation, infection, and air embolism and the defendant, as a physician, was aware at the time of the tampering that her actions could have created health risks for her patients was sufficient to support a jury's finding that Moyer acted with reckless disregard of serious health risks to which her actions exposed her critically ill patients.

24 U.S. v Nancy L. Moyer (No /8th Circuit, 1999) Decision (cont) Evidence that Moyer stole morphine from an elderly patient who was dying of lung disease and who was taking morphine to relieve pain through the dying process, was sufficient to support a finding that the defendant acted under circumstances manifesting extreme indifference to the risk of pain and suffering to which her tampering exposed the patients. Evidence that Moyer stole morphine from an elderly patient who was dying of lung disease and who was taking morphine to relieve pain through the dying process, was sufficient to support a finding that the defendant acted under circumstances manifesting extreme indifference to the risk of pain and suffering to which her tampering exposed the patients. The court found that Moyer's prison sentence was typical of similar product tampering cases around the country. The court found that Moyer's prison sentence was typical of similar product tampering cases around the country.

25 U.S. v. Ashton Paul DAIGLE

26 Oct 2008 Anesthesiologist’s complaint Anesthesiologist’s complaint Hospital Pharmacy staff checked vials in Pyxis machines in 9 Operating Rooms Hospital Pharmacy staff checked vials in Pyxis machines in 9 Operating Rooms Removed 67 suspect Fentanyl vials – Removed 67 suspect Fentanyl vials – FDA OCI sent 64 suspect vials to the Forensic Chemistry Center FDA OCI sent 64 suspect vials to the Forensic Chemistry Center

27 DAIGLE’S ACCESS TO PYXIS DATEACCESS WORK SCHEDULE 09/24/08210:50a - 7:38p 09/25/08210:50a - 7:42p 09/26/08210:53a - 7:34p 09/29/08310:55a - 7:29p 09/30/08111:23a - 7:30p 10/02/08110:55a - 7:27p 10/03/08310:55a - 5:31p 10/05/081absent 10/06/08211:33a-7:39p 10/07/08310:52a - 7:32p 10/08/08810:54a - 7:37p 10/09/08210:56a - 1:30p 10/10/0857:34p - unknown 10/12/083absent 10/13/081110:58a - 7:30p 10/14/08310:58a - 4:39p 10/15/081310:54a - 7:32p 10/16/082511:00a - 7:25p 10/17/081410:59a - 7:29p 10/23/08410:58a - 7:23p Pyxis accessed 108 times in 8 Operating rooms over 20 days As much as 25 times in one day Used “Cancelled/Remove” access code

28 U.S. v. Ashton Paul DAIGLE Forensic Chemistry Center Analysis 63 of 64 vials contained glue-like residue on metallic crimp tops. 63 were firmly affixed and not able to spin. The one remaining vial’s top fell off. 63 of 64 vials contained glue-like residue on metallic crimp tops. 63 were firmly affixed and not able to spin. The one remaining vial’s top fell off. Random sample of 20 vials Random sample of 20 vials * ALL 20 contained less than 2 mcg/mL of the labeled 50 mcg/mL of Fentanyl labeled 50 mcg/mL of Fentanyl * 18 had a minimum of 2 punctures on top & bottom stopper surfaces & bottom stopper surfaces

29 Fentanyl Vials - Evidence

30

31

32 U.S. v. Ashton Paul DAIGLE December 16, 2008 Indicted on: 108 counts of Tampering with a Consumer Product 108 counts of Tampering with a Consumer Product 18 USC § USC § counts of Creating a Counterfeit Controlled Substance 67 counts of Creating a Counterfeit Controlled Substance 21 USC §841(a)(2) and (b)(1)(C) 21 USC §841(a)(2) and (b)(1)(C) 4 counts of Adulteration of a Drug 4 counts of Adulteration of a Drug 21 USC §331(b) & §333(a)(2) 21 USC §331(b) & §333(a)(2)

33 U.S. v. Ashton Paul DAIGLE DAIGLE’S Proffer/Polygraph: Battled drug addiction since he was 11 years old Battled drug addiction since he was 11 years old Did not sell, give, trade or transfer drugs to others – for personal use Did not sell, give, trade or transfer drugs to others – for personal use Shot up in restroom and refilled vials with saline at first, then tap water from restroom sink Shot up in restroom and refilled vials with saline at first, then tap water from restroom sink Removed from BCH and used Fentanyl, Morphine, Versed® ( Midazolam ), Sufenta® ( Sufentanil ) and Nubain® ( Nalbuphine ) for personal use Removed from BCH and used Fentanyl, Morphine, Versed® ( Midazolam ), Sufenta® ( Sufentanil ) and Nubain® ( Nalbuphine ) for personal use Stole prescription controlled substances from patients while he worked at Windsor Healthcare Center prior to his employment at BCH Stole prescription controlled substances from patients while he worked at Windsor Healthcare Center prior to his employment at BCH

34 U.S. v. Ashton Paul DAIGLE Daigle Plea Agreement: (June 1, 2009) Pled guilty to Pled guilty to * 5 counts of Tampering with a Consumer Product * 1 count of Creating a Counterfeit Controlled Substance Government recommends: Government recommends: * 1 full year of blood testing for HIV and Hepatitis * Surrender of Nursing license * Never to work in the healthcare field or in any medical capacity or in any medical capacity * No less than 54 months prison time & 3 years supervised release thereafter 3 years supervised release thereafter

35 U.S. v. Ashton Paul DAIGLE Lessons Learned or to be Learned! Do not send out evidence to be tested Do not send out evidence to be tested Call FDA/OCI first – State & Local Police will end up turning it over to us anyway Call FDA/OCI first – State & Local Police will end up turning it over to us anyway Addicts are Addicts…Understand you may not understand! Addicts are Addicts…Understand you may not understand! Listen to your employees – they are an extension of your eyes and ears. Listen to your employees – they are an extension of your eyes and ears. Don’t assume the patients have a tolerance for controlled substances. Don’t assume the patients have a tolerance for controlled substances. If an employee should not have access to a particular drug – don’t grant him access! If an employee should not have access to a particular drug – don’t grant him access! Review your reports. Review your reports.

36 U.S. v. Kristen Diane PARKER “I have a crazy fascination with needles.. “I have a crazy fascination with needles.. I just like the way they feel! ;)” I just like the way they feel! ;)”

37 U.S. v. Kristen Diane PARKER SUMMARY Hospital scrub tech (Parker) was taking fentanyl-filled syringes and replacing them with saline-filled syringes – syringes she had already used. Hospital scrub tech (Parker) was taking fentanyl-filled syringes and replacing them with saline-filled syringes – syringes she had already used. Parker had Hepatitis C – exposed approximately 5,000 patients from RMC and over 1,200 from ASC Parker had Hepatitis C – exposed approximately 5,000 patients from RMC and over 1,200 from ASC Parker knew she had Hep C Parker knew she had Hep C

38 U.S. v. Kristen Diane PARKER BACKGROUND March 24, 2009 – Parker stuck a nurse with a needle that she kept in her front pocket – counseled, documented & drug tested. March 24, 2009 – Parker stuck a nurse with a needle that she kept in her front pocket – counseled, documented & drug tested. March 30, 2009 – Negative drug test. Returned to work. Specific drug test for Fentanyl not conducted!! March 30, 2009 – Negative drug test. Returned to work. Specific drug test for Fentanyl not conducted!! April 13, Employee reported seeing Parker place a syringe in her front pocket from an anesthesia cart. April 13, Employee reported seeing Parker place a syringe in her front pocket from an anesthesia cart. Parker immediately taken from OR and drug tested – this time for Fentanyl. Parker immediately taken from OR and drug tested – this time for Fentanyl. April 22, 2009 – Positive Fentanyl test. Parker terminated from RMC. April 22, 2009 – Positive Fentanyl test. Parker terminated from RMC. April 23, RMC reported to Denver PD potential theft. April 23, RMC reported to Denver PD potential theft.

39 U.S. v. Kristen Diane PARKER JUNE 30, 2009 INTERVIEW Denver PD interviewed Parker – she confessed to taking the Fentanyl-filled syringes off the anesthesia cart, placing a needle on it, shooting up, refilling with saline and placing the contaminated syringe back onto the anesthesia cart. She carried a couple previously used syringes in her front scrub pocket so she could capitalize on her “opportunity” when anesthesiologists left the Fentanyl-filled syringes on their carts unattended – even if for only a few seconds. Denver PD interviewed Parker – she confessed to taking the Fentanyl-filled syringes off the anesthesia cart, placing a needle on it, shooting up, refilling with saline and placing the contaminated syringe back onto the anesthesia cart. She carried a couple previously used syringes in her front scrub pocket so she could capitalize on her “opportunity” when anesthesiologists left the Fentanyl-filled syringes on their carts unattended – even if for only a few seconds.

40 U.S. v. Kristen Diane PARKER Parker prowled OR to OR looking for unattended carts with syringes placed on top by anesthesiologists when they prepared for upcoming surgeries. Parker prowled OR to OR looking for unattended carts with syringes placed on top by anesthesiologists when they prepared for upcoming surgeries. If asked what she was doing – she would ask if anyone needed help preparing for surgery – or she would claim she was looking for a band-aid or cleaning up. If asked what she was doing – she would ask if anyone needed help preparing for surgery – or she would claim she was looking for a band-aid or cleaning up. Claimed it never crossed her mind about contaminating the syringes she used and placed back on the anesthesia cart. Claimed it never crossed her mind about contaminating the syringes she used and placed back on the anesthesia cart. INTERVIEW

41 U.S. v. Kristen Diane PARKER June Parker started work at ASC. She claimed she was still working at RMC and would prefer them to NOT contact them for references – they did not… June Parker started work at ASC. She claimed she was still working at RMC and would prefer them to NOT contact them for references – they did not… Parker claimed to have switched out syringes at RMC times and about five times at ASC. Parker claimed to have switched out syringes at RMC times and about five times at ASC. Parker admitted to sharing needles while shooting up with heroin while she lived in New Jersey a few months before starting work at RMC. She believed that is where she got Hep C. Parker admitted to sharing needles while shooting up with heroin while she lived in New Jersey a few months before starting work at RMC. She believed that is where she got Hep C. INTERVIEW

42 U.S. v. Kristen Diane PARKER INTERVIEW Parker denied knowing she had Hep C and then contradicted herself a few times stating she had been informed her first day of work but did not think it was a big deal. Parker denied knowing she had Hep C and then contradicted herself a few times stating she had been informed her first day of work but did not think it was a big deal. July 1, Denver PD and DEA immediately referred to FDA OCI due to tampering – significantly greater penalties than state charges. July 1, Denver PD and DEA immediately referred to FDA OCI due to tampering – significantly greater penalties than state charges. July 3, 2009 – we arrested Parker on a criminal complaint. July 3, 2009 – we arrested Parker on a criminal complaint.

43 U.S. v. Kristen Diane PARKER July 23, 2009 and August 27, 2009– Parker was indicted on: July 23, 2009 and August 27, 2009– Parker was indicted on: * Tampering with a Consumer Product 18 USC §1365(a) 18 USC §1365(a) * Obtaining a Controlled Substance by Deceit or Subterfuge Deceit or Subterfuge 21 USC §843(a)(3) and (d)(1) 21 USC §843(a)(3) and (d)(1) Trial set for September 28, 2009 Trial set for September 28, 2009 Parker was denied bond and remains in jail. Parker was denied bond and remains in jail.

44 U.S. v. Kristen Diane PARKER RMC “War Room” & swift action RMC “War Room” & swift action Almost 5,000 were tested Almost 5,000 were tested Center for Disease Control (CDC) conducted genetic sequencing analysis on cases CDPHE identified as probable in contracting Hep C from Parker. Center for Disease Control (CDC) conducted genetic sequencing analysis on cases CDPHE identified as probable in contracting Hep C from Parker. Obtained medical releases from 35 highest risk patients (genotype 1b, no previous history) Obtained medical releases from 35 highest risk patients (genotype 1b, no previous history)

45 U.S. v. Kristen Diane PARKER September 24, 2009 CDC Report: CDC Report: * 16 genetic sequencing analysis completed * 16 samples genetically linked, including Parker * 97% level of confidence that Parker is source to other 15 cases to other 15 cases

46 U.S. v. Kristen Diane PARKER September 25, 2009 Pled guilty to Pled guilty to * 5 counts of Tampering with a Consumer Product * 5 counts of Obtaining a Controlled Substance by Deceit or Subterfuge Deceit or Subterfuge Government recommends: Government recommends: * Full cooperation and disclosure * 1 full year of blood testing for HIV * Surrender of any license/certification * Ceasing to ever work in the healthcare field or in any medical capacity or in any medical capacity * no less than 240 months prison time & 3 years supervised release thereafter 3 years supervised release thereafter Sentencing set for January 22, 2010 Sentencing set for January 22, 2010

47 U.S. v. Kristen Diane PARKER Lessons Learned or to be Learned Lessons Learned or to be Learned Immediately notify FDA/OCI and DEA for theft & tampering Immediately notify FDA/OCI and DEA for theft & tampering Do a good background on employees that will have access to controlled substances Do a good background on employees that will have access to controlled substances Test for Fentanyl in addition to other drug screens Test for Fentanyl in addition to other drug screens Identify potential patients Identify potential patients Assume and prepare for us to get copies of patient files with proper subpoenas Assume and prepare for us to get copies of patient files with proper subpoenas Share your information/findings with us – work with us, but not for us or against us Share your information/findings with us – work with us, but not for us or against us Be ready for the onslaught of the press – good and bad (it’s rarely good….) Be ready for the onslaught of the press – good and bad (it’s rarely good….)

48 Contact Information Special Agent Martha Hughes Office (205)

49 Report a Problem Drugs, Medical Devices…(MedWatch) To Report an Emergency To Report a Non-Emergency Report Suspected Criminal Activity For Industry: Reportable Food Registry


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