David Kwiatkowski, who was infected with the virus, allegedly stole vials of the narcotic fentanyl, injecting himself and then left the used needles behind, allowing them to be reused on patients. He is awaiting trial on federal charges.
Kwiatkowski worked as a radiology technician in several states, including Maryland. Investigators say five patients in Maryland contracted hepatitis C and 1,700 were exposed to the virus, along with thousands more elsewhere.
The report released Wednesday looked at what could have been done to stop Kwiatkowski earlier in Maryland, where he worked at four hospitals from 2008 to 2010, The Baltimore Sun reported. The Maryland Department of Health and Mental Hygiene prepared the report.
"I think that there were missed opportunities that could have stopped Mr. Kwiatkowski from diverting drugs in Maryland," Dr. Lucy Wilson, chief of the state epidemiology center, said.
In several cases, Kwiatkowski moved on while investigations were in progress, the report said. Findings were not given to his next employer.
At one Maryland hospital where Kwiatkowski was suspected of stealing drugs, a manager reported on his work to the contracting agency that employed him, describing him as a hard worker and "very professional," the report said.
Regulatory agencies in some cases depended on medical workers to be honest about criminal records, the report said. At many hospitals, staffers were reluctant to give bad reviews.
"We found there wasn't one single overarching issue, but really it was instead multiple system-wide vulnerabilities in multiple arenas," Wilson said.