Hello,

I am writing to let you know about an issue we are addressing related to drug testing. During routine quality assurance practices at RIDOH’s Forensic Drug Chemistry Laboratory this past fall, a laboratory quality issue involving a cocaine detection was identified. The specifics are outlined in the attached letter.

 

The lab’s quality assurance work involves proficiency testing, which is an external quality and accuracy assessment process where staff are given blinded samples to test with known results. (These samples are not associated with criminal cases.) In a single laboratory proficiency testing event in the fall of 2022, a small amount of cocaine was detected by a RIDOH laboratory scientist in their sample when it should not have been present. This resulted from carry-over contamination from another sample. This issue triggered an investigation into potential underlying causes, along with an evaluation of potential impacts on law enforcement cases. Although this issue arose during analysis of a quality assurance test case, not in relation to a criminal case, we brought this issue to the Rhode Island Attorney General’s Office out of an abundance of caution.

 

In addition to working with the Attorney General’s Office, we conducted thorough reviews of RIDOH’s laboratory procedures and staff. Details are in the attached letter, but I am providing some highlights here:

 

  • The laboratory scientist involved in the cross-contamination issue during the proficiency test has been temporarily removed from testing law enforcement cases that potentially contain cocaine.
  • Our detailed review of 13 years of testing records for this laboratory scientist, and other staff did not reveal any quality concerns.
  • The properties of cocaine and the process of testing for cocaine make carry-over contamination more of a concern for cocaine than for other controlled substances. Unlike other powdered substances, cocaine’s fine particles can get into the air and settle on surfaces. Additionally, the instruments we now use to identify controlled substances are much more sensitive in order to detect fentanyl and other opioids. Even very minute amounts of cocaine can be detected by this newer instrumentation. Our analysis identified these as potential factors in this instance of carry-over contamination.
  • There have been no recommendations to modify any of the lab’s sampling processes during any of our recent accreditation audits and the employee involved was not in violation of current protocols. However, we regularly undertake evaluations to ensure that best practices are in place at the laboratory.

     

    I will keep you up to date about anything new on issue.

 

Joseph Wendelken | Public Information Officer

Rhode Island Department of Health

3 Capitol Hill, Room 401; Providence, Rhode Island 02908

 

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March 17, 2023

Timothy Healy

Chief, Narcotics and Violent Crime Unit

Office of the Attorney General

Dear Mr. Healy,

I am writing to provide you with information about an incident at the Rhode Island Department of Health (RIDOH)’s Forensic Drug Chemistry Laboratory (FDCL).

Incident overview

RIDOH’s FDCL provides testing services for detection of controlled substances in seized drugs or in evidence related to law enforcement cases. This includes many cases that involve the Rhode Island Attorney General’s Office. In the course of routine quality assurance practices at the FDCL, a laboratory quality issue involving a cocaine detection was identified last fall during a proficiency test.

The FDCL’s quality assurance work involves proficiency testing, which is an external quality and assurance assessment process in which staff are given blinded samples to test from an independent vendor with known results. These samples are not from seized samples associated with criminal cases. In a laboratory proficiency testing event in the fall of 2022, a small amount of cocaine was detected by a RIDOH laboratory scientist in their sample when it should not have been present. The carry-over contamination from another sample into this test case sample triggered an investigation into potential underlying causes, along with an evaluation of potential impacts on police cases. Although this issue arose during analysis of a quality assurance test case, not in relation to an actual criminal case, the FDCL is notifying the Rhode Island Attorney General’s Office of this issue.

Procedural review

All laboratory protocols and quality systems are externally reviewed by the American National Standards Institute’s National Accreditation Board, our laboratory accreditation provider. There have been no recommendations to modify any of the lab’s sampling protocols during any of our recent accreditation audits.

Following the identification of this issue a comprehensive review of laboratory testing practices was embarked on. As part of this review, the FDCL’s Laboratory Supervisor supervised all laboratory scientists while preparing and testing samples. FDCL’s review also involved detailed technical root cause evaluations to identify potential sources of substance carry-over between samples. All laboratory scientists were found to be following FDCL’s Standard Operating Procedures. We regularly undertake evaluations to ensure that best practices are in place at the laboratory.

The properties of cocaine and the process of testing for cocaine make carry-over contamination more of a concern for cocaine than for other controlled substances. Unlike other powdered substances, cocaine’s fine particles can get into the air and settle on surfaces. Additionally, the instruments we now use to identify controlled substances are much more sensitive in order to detect fentanyl and other

opioids. Even very minute amounts of cocaine can be detected by this newer instrumentation. Our analysis identified these as potential factors in this instance of carry-over contamination.

Staff review

The FDCL undertook a comprehensive review of prior laboratory proficiency testing and personnel competency records to determine if there was any impact beyond cocaine detections. During a review of 13 years of proficiency testing results, no other instances of false detections of any substances were identified. Additionally, testing records showed consistency among results across all laboratory scientists prior to this incident.

Follow-up evaluation of potential case impacts focused on the laboratory scientist with the false detection in the proficiency testing because other laboratory scientists who repeated analysis of that proficiency sample obtained the expected results. This laboratory scientist has been removed from testing samples in law enforcement cases that potentially contain cocaine until they can be retrained on updated procedures and best practices.

Case reviews

Out of an abundance of caution, a law enforcement case review was done on all evidence samples tested by this laboratory scientist from their initial approval for testing powder substances in June 2021 through November of 2022 when the carry-over contamination was first noted. During this time frame, the laboratory scientist worked on 1,313 law enforcement cases. Any evidence still in FDCL’s possession after the false cocaine detection was reviewed. Exhibits in cases in which cocaine contamination could not be ruled out were re-tested by a second laboratory scientist prior to releasing those results. All other law enforcement cases were evaluated for potential impacts of detections of low levels of cocaine.

549 law enforcement cases did not contain any detections of cocaine, and therefore are unaffected. For 488 of the remaining law enforcement cases, the signal strength on the testing instrument we use was evaluated. If the signal was sufficiently strong, indicating high confidence that cocaine was present, we were able to rule out low-level cross contamination. For 436 law enforcement cases, the instrument’s signal strength was able to rule out low-level cross contamination. For 52 law enforcement cases, the instrument’s signal strength for cocaine was weaker, meaning that cocaine was less present. These 52 cases all involved cocaine and other illicit substances. FDCL would need to do re-testing to determine whether the small amounts of cocaine included in these 52 law enforcement cases were the result of carry-over contamination. If evidence on these cases remains and can be retrieved from law enforcement agencies for re-testing, re-testing will be done immediately.

There are an additional 263 cases where the impact is still being determined. Those cases involve samples with less than 10 grams of controlled substances. These cases may or may not involve cocaine. They are still being reviewed.

Sincerely,

Glen R. Gallagher, Ph.D., MLS (ASCP)CM

Director, Rhode Island State Health Laboratories

Rhode Island Department of Health

 

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