June 2015

In Gratitude for a Simple Gesture of Respect

Newsweek ran a feature article on drug diversion in hospital settings
Newsweek ran a feature article on drug diversion in hospital settings

The cover story of Newsweek June 18, 2015 edition is When Drug Addicts Work in Hospitals, No One is Safe.

The lengthy article was written by Kurt Eichenwald and was the result of an interview and correspondence with David Kwiatkowski, the radiologic technician who was sentenced to 39 years in prison after infecting patients with hepatitis C through unsafe injection practices. Kwiatkowski, who was infected with hepatitis C, stole injectable pain medications from the hospital where he was working and injected himself. He changed the needle, rinsed the syringe with water, refilled the syringe with saline and put these syringes back on the medication cart for use with patients. In this way, at least 45 patients in seven states were infected with hepatitis C. One patient has died from the infection.

Regrettably, this scenario is not unusual in the United States. The CDC estimates that 30,000 people may have been exposed to hepatitis C over the past decade by infected hospital employees who have used narcotics intended for patients. Federal researchers estimate that 100,000 healthcare workers in the United States are addicts and their theft of narcotics from patients is believed to be widespread. As many as 379,000 health care workers in the United States are addicted to drugs or alcohol, according to New Jersey pharmacist Mitch Sobel, who delivered this information at a recent New Jersey Department of Health meeting.

Getting back to the excellent Eichenwald article, what is unusual is that Kwiatkowski apologized…and desribed how he diverted drugs so that we can correct the healthcare delivery system to prevent harm to the public.

Since he is not eligible for parole, Kwiatkowski has nothing to gain from his disclosures. In fact, he and prison officials fear the article might anger other inmates and place him in danger.

As one who contracted hepatitis C through unsafe injection practices, i want to commend Mr Kwiatkowski for apologizing and sharing his story. It is so meaningful to victims when there is an apology; I still yearn for the gift of this simple, but profound gesture of respect. It is very difficult to fully heal from harm of this magnitude without an apology–it is as if something is missing, and closure is impossible.

Kwiatkowski not only apologized, but gave us a clear picture of how diversion takes place in hospitals. This important “insider” knowledge–not unlike when casinos ask cheaters to help them catch other cheaters–will help us make the changes that are long overdue. As we reported in a previous blog, HONOReform is helping to head efforts at a national level to help prevent drug diversion. We encourage all stakeholders to join us.

In the Newsweek article, Kwiatkoski said he is “haunted by the knowledge that he hurt so many people and believes he needs to make amends by revealing the scope and methods of this medical crime that endangers un unknowing public. “

Somebody has to tell how it’s done, how easy it is and how the structure of the hospitals isn’t any good to stop it,’ he says of drug diversion.”

Examining all ways to prevent drug diversion has never been more important. Patients throughout the country are harmed, and there is no national system in place to stop diverters. From just one patient affected by unsafe injection practices, thank you, David Kwiatkowski, for your candor. We need you and others continue to tell us how to fix the system that is so easy to violate.


What Does It Mean for Patients?

Lauren Lollini is a patient safety advocate who has been integral in changing laws to keep patients safe as well as a member of the Drug Diversion Prevention Committee.
Lauren Lollini is a patient safety advocate who has been integral in changing laws to keep patients safe as well as a member of the Drug Diversion Prevention Committee.

I am grateful HONOReform had the opportunity to respond in the June 12 Concord Monitor to the horrible but all too common report of provider drug diversion by a healthcare worker.

As Steve Langan, HONOReform executive director, said, “Drug diversion may likely be the most enormous elephant in the room, in healthcare.” Anyone who has tried to pay attention to the many conversations on healthcare in the United States knows that there are many gaps and there have been many breakdowns.

If we continue to look the other way and deny and ignore the fact of widespread drug abuse and drug diversion among healthcare workers, more and more systematic challenges will develop.

According to recent statistics, there are as many as 379,000 addicted healthcare workers right now in the United States.

What does this mean for patients? They may not be receiving the medication they have been prescribed, in the recovery room or in other hospital settings. And, worse yet, they may receive an infection of bloodborne pathogens, such as hepatitis C or HIV.

At HONOReform, we believe a first priority in American healthcare is protocol and regulations that prevent drug diversion. This is a problem that can and must be fixed.

Robust materials developed by partners at the Safe Injection Practices Coalition the One and Only Campaign will soon be in place. We welcome the opportunity to help distribute these materials to leadership at healthcare facilities throughout the country.

Messaging and education are essential, important; but, in this case, we need government leaders at all levels to take a stand. Patients have been placed over and over in a vulnerable position, and addicted healthcare workers continue to practice with very little oversight and not nearly enough intervention.

In the near future, we will make an announcement of an upcoming meeting on drug diversion prevention.

Nebraska Methodist College Junior Level Nursing Student by Brittney L Commins


Listening to Dr. McKnight was inspiring. Listening to her heart-breaking struggles and what she has overcome has motivated me to commit to safe injection practices. I want to make that if I were ever in a situation where I had witnessed an incident similar to Dr. McKnight’s that I would take action to prevent injury to the patient. Patients need to be comfortable and be able to trust their health care providers; delivering positive and safe patient care will empower and establish an excellent patient to provider relationship. I will strive to be aware of my surroundings and the cares being done by fellow nurses and physicians, making sure to advocate for the safety of the patient. Read more

Preparing Future Healthcare Providers

" A Never Event" is being used in the curriculum of numerous healthcare training programs.
” A Never Event” is being used in the curriculum in numerous healthcare training programs.

Over time, some colleges and universities have incorporated “A Never Event: Exposing the Largest Outbreak of Hepatitis C in American Healthcare History” by McKnight and Bennington into their training of healthcare providers. This is a wonderful way to educate young providers about injection safety and patient safety in general. We always enjoy interacting with the students when we are invited to join class. It is very rewarding to us, because in the words of a nursing professor at Johns Hopkins School of Nursing, “Today you have spoken to a hundred new nurses. But they will never forget your story, and through their hands you have made healthcare safer for thousands.”

We have gathered together some thoughts of the students and professors from the past months and have used them to compose this six minute video for your enjoyment.

We know of some of the training programs that use A Never Event, but we suspect that there are others that we are unaware of. If you know of any that are not mentionned in the video, please let us know by emailing evelyn@www.HONOReform.org. Thank you!

Hepatitis C and preventive measures by Dr Mudasir Firdosi

We would like to thank Dr. Mudasir Firdosi for helping to highlight Hepatitis C as a truly global issue. This is re-printed from a post which appeared in mid-May.

Kashmir valley is witnessing another disaster in the form of Hepatitis C epidemic. In some villages in Kokernag area, the number of cases is around 40% of the total population. In spite of media pressure, and demand from local population, authorities are still contemplating curbing the further spread of this infection. Similar scenario exists in other districts of the valley like Shopian, Kupwara, and Srinagar.

Hepatitis C is not transmitted by routine personal contact and there needs to be an actual transfer of the virus via blood, blood products and body fluids, from one person to another. From the sociodemographic profile of the rural population, one can easily exclude intravenous drug abuse or sexual contact as the cause of the current epidemic in majority of cases.
Read more