Learning from our Mistakes: A New Model of Malpractice Resolution
“Dear sir or madam: you have been potentially exposed to Hepatitis C, Hepatitis B and HIV through unsafe practices by your healthcare provider. Please come to our facility to be tested.”
Those were the opening sentences of an official letter that I received from the Nebraska Health Department in 2002.
Thus began my involvement in malpractice litigation as a plaintiff.
But through this experience, we have developed a new model of malpractice resolution – one that requires not only compensation for the victim, but also safeguards the welfare of the community through remediation of medical error.
I was honored to share this model in a TEDx Omaha Talk last month. Please take a look at the talk, share it with your network, and join our campaign by following HONOReform Foundation’s Facebook page!
“If this can happen at Mass General, it can happen anywhere”
Last week, in a blog I wrote on the patient notification in Utah, a situation that is directly related to drug diversion, I mentioned the recent fine levied against Massachusetts General Hospital by the Drug Enforcement Agency.
If this can happen at Mass General, many of us thought, it can happen anywhere. And, sadly, it does.
Among the many acts of drug diversion mentioned in the Settlement Agreement, which is part of the public record, are incidents that involve improper use of injections.
Here is the entire article from the September 28 Boston Globe: “Mass General to pay $2.3 million toresolve allegations of drug diversion,” written by staff writer Travis Andersen.
4800 Utah Patients could have been exposed to Hepatitis C through Unsafe Injections
It was revealed late last month that nurse Elet Neilson, also known as Elet Hamblin, who has a confirmed case of hepatitis C, was fired by McKay-Dee Hospital of Ogden, Utah in November 2014 (“Hospital acting cautiously,” Oct. 31). At least one of the 4,800 patients who had contact with this nurse during her tenure at the hospital, June 2013 to November 2014, has been infected with the same genotype of hepatitis C as Neilson.
On behalf of HONOReform, a national patient advocacy organization with a focus on safeguarding the medical injection process, I join these patients and their family members in hoping and praying that none of these patients has been infected with this life-threatening disease. I encourage all of these patients to contact the Utah Department of Health and get tested. Read more
Drug diversion, “anytime prescription drugs are obtained or used illegally,” is like climate change, in a way. In our experience, most people either do not want to believe it exists or cannot believe it exists. When you start to tell them about it, they close their ears. It’s not that they are rude or there’s a short attention span. It’s just too frightening—unexpected and baffling—too much for them to take in.
We are not in the business of creating wariness, mistrust or fear. We are simply in the business of safeguarding the medical injection process. One of the ways that drugs are diverted in healthcare systems or clinics is through improper injections.
Oftentimes—at least three times that we are aware of, three outbreaks in which multiple patients were infected with hepatitis C—an addicted, infected healthcare worker will inject medication prescribed to a patient into himself or herself, refill these vials with saline then put them reuse them.
If there’s even a speck of infected blood in that injection device, the patient who receives this injection could become infected. Also, the patient is not receiving the proper dose of prescribed medication.
When it comes to drug diversion, there are many overlapping patient safety and worker safety issues. Drug diversion has to be prevented. And, to prevent the problem, to really mobilize to prevent this problem, we need a clear, consistent and acknowledged definition of the problem.
Once again, it’s CDC to the rescue!
Just Google “CDC Drug Diversion,” and the ongoing problem is made clear. On the CDC page titled “Risks of Healthcare Associated Infections from Drug Diversion,” there are sections titled “Outbreaks,” “Prevention Resources,” “Enforcement Agencies,” and much more.
We have touted this work before, this extraordinary ongoing science and research collection, but it bears repeating, especially as we are working toward gathering for a national meeting on drug diversion prevention in early 2016.
The problem is clear, just a click away. We encourage all affected agencies and organizations to forge past the denial that often develops around this subject and work together to develop a plan and take action.