DENVER -- The chief medical officer of the state health department told 7NEWS that changes are coming to his department in the wake of the hepatitis C scare in Colorado and Rose Medical Center is implementing new procedures and reiterating old policies to employees regarding the handling of narcotics in the hospital.

It's evident the hepatitis scare has exposed a number of loopholes in oversight of and within Colorado's medical community including no licensing or specific state requirements for surgical techs, no real ability to track terminated hospital workers who are under criminal investigation or with criminal charges pending, and no mechanism for the state to easily cross reference outbreaks within hospitals and incidents involving hospital employees.

Kristen Parker, who had tested positive for hepatitis C last year, was fired from Rose Medical Center after failing a drug test in April.

The loopholes in oversight allowed Parker to get another job and continue working in the medical field for another two months, potentially infecting more patients with the disease.

Records say, in April, she was in a part of Rose Medical Center that she was not authorized to access and police say she later admitted to injecting herself with syringes filled with the painkiller Fentanyl, filling the empty syringes with saline and then putting the used, dirty needles back into service at the hospital.

About 4,700 patients from Rose Medical Center and 1,000 from Parker's subsequent employer, Audubon Surgical Center, will receive letters suggesting they be tested for hepatitis C.

The Chief Medical Officer for Colorado Department of Public Health and Environment, Ned Calonge, told CALL7 Investigator Theresa Marchetta that his agency and the Centers for Disease Control and Prevention agree they are dealing with an "unprecedented" situation.

He said the CDPHE gets about 4,000 newly reported cases of hepatitis C every year.

“The fact that two cases had surgery at Rose doesn’t give you enough reason to say that’s where they got it,” said Calonge referring to the earliest stage of the CDPHE investigation.

Calonge told Marchetta that, at the time all this occurred, there would have been no correlation between a surgical tech failing a drug test and the potential for patient harm, even if the surgical tech had hepatitis C.

"It's unlikely the person who fired her [from Rose Medical Center] knew she had hep C," said Calonge adding, CDPHE will now adopt a new strategy including better cross-referencing of internal databases.

"If we have two cases of blood-borne illness linked to a licensed facility, let's look at the [occurrence] reports to see if there's a connection," said Calonge. "Occurrence Reports" are filed by medical facilities like the one Rose Medical Center filed after Parker's suspected drug diversion.

According to the April 13 report, Rose Medical Center "conducted an internal investigation. The facility notified the Drug Enforcement Administration and the police department. A staff member was observed in an operating room to which s/he was not assigned. S/he was seen looking into an anesthesia cart in that room which contained the 2cc of Fentanyl syringe. The staff member was interviewed and stated s/he was helping set up for a case. The staff member denied taking anything from the anesthesia carts. S/he was drug tested and the results were positive for Fentanyl. The staff member was terminated. The facility implemented new procedures. Syringes will not be drawn up or vials taken into the room until staff are able to be in constant attendance of the drugs. Drugs will never be left unattended in the operating room."

On May 6, CDPHE included, "The Department conducted a written report review and found that the facility acted appropriately by reporting the occurrence timely, notifying the appropriate persons and agencies, conducting an internal investigation, interviewing staff, drug testing the suspect staff member, terminating the employee and implementing new procedures. No deficient practice was cited. The Department will review this occurrence prior to any survey or upon receipt of any complaint that may be filed against this facility."

In a statement to 7NEWS, officials with Rose Medical Center said they have, "reiterated its policy regarding narcotics. Nothing is to be drawn or laid out in surgical or other areas prior to having the patient in the room or without direct and constant physical supervision of those drugs."