Survivor Stories Blog
Learn to know what you don’t know
HONOReform is proud to reprint board member Pam Demski-Hart’s recent contribution to the CDC’s Safe Healthcare blog. Pam is the principal and founder of Healthcare Accreditation Resources LLC, a consulting service for ambulatory healthcare and dental facilities. Following is part two of a blog series recounting her personal observations of unsafe injection practices in healthcare settings. Pamela asks, “How do we get every healthcare worker on the same page when it comes to infection control practices?”
In my last blog post, I discussed the differences between reality and perception when it comes to what safe injection/infection control practices are — and are not.
So, how do we get every healthcare worker on the same page when it comes to reinforcing correct procedures? Especially when some healthcare workers are in a sort of denial that unsafe practices actually do happen. Or, worse yet, when they are absolutely convinced they are doing the right thing when, in fact, they couldn’t be more wrong. Read more
You Won’t Believe the Things I See. And Hear.
HONOReform is proud to reprint board member Pam Demski-Hart’s recent contribution to the CDC’s Safe Healthcare Blog. Pam is the principal and founder of Healthcare Accreditation Resources LLC, a consulting service for ambulatory healthcare and dental facilities. She shares in this blog her personal observations of unsafe injection practices in healthcare settings. Pam discusses the differences between reality and perception when it comes to what infection control practices are — and are not. The blog is posted here in its entirety. We urge you to share with all healthcare providers, and to combat the dangerous denial of the presence of unsafe injections.
They greet me at the facility door with a handshake and a cheerful comment, “We’re pretty sure we’re OK!”
And that’s when I cringe and prepare myself. Read more
HONOReform’s Annual Report
At this time of year, we review our activities of the previous year. Join us as we look back on 2015 through the lens of HONOReform.
OUR MISSION AND VISION
HONOReform is the only national advocacy organization dedicated to protecting patients by safeguarding the medical injection process “from manufacturing to disposal.” Our vision is a nation in which healthcare providers always follow fundamental injection safety practices that protect patients with every injection.
Evelyn McKnight shared her story and the ongoing efforts of HONOReform at the landmark World Health Organization Safe Injection Gliobal Network meeting. At the end of the meeting, WHO representatitves shared the goal of having single-use only injection devices in use in developing countries by 2020. Additionally, Steve Langan represented HONOReform in Glasgow, Scotland at the first international meeting hosted by the World Hepatitis Alliance.
PRESENTATIONS AND MEDIA
Led by co-founder and president Evelyn McKnight, who frequently presents her story and the ongoing need to always use safe healthcare practices, HONOReform presented at 30 events in 2015 attended by over 2500 people. HONOReform was featured in local and national media dozens of times in 2015, including an appearance in the May 21 US News and World Report article, “Unsafe Injections Put Patients in Peril.”
Evelyn and HONOReform are active on social media, particularly twitter (#HONOReform). On our streamlined website, click on “JOIN THE CONVERSATION” to receive up-to-the-minute information from HONOReform (on Twitter and Facebook). Also, be sure to check out and subscribe to the HONOReform blog, “Survivor Stories,” edited by Evelyn and Lauren Lollini. To submit an idea for our blog or an article, contact Steve Langan at 402.659.6343 or steve@www.HONOReform.org.
OUR ACADEMIC PARTNERS
HONOReform appreciates the many opportunities this year to meet, in person and online, with students from numerous universities and colleges, as they studied the consequences of unsafe injections. We welcome the opportunity to share the HONOReform story and highlight the need to always emphasize injection safety. Our academic partners include University of Nebraska-Omaha, Midland University, Methodist Nursing College, the College of St Mary, St Louis Univerity and Southeast Community College – among others.
THE SIPC AND THE CAMPAIGN
HONOReform is a proud member of the Safe Injection Practices Coalition (SIPC), which provides support for the One and Only Campaign. The SIPC continues to develop and distribute its award-winning materials, and we continue to raise awareness among healthcare providers and patients about the absolute need for safe injection practices. As always, please contact HONOReform and allow us to help you access the matierals that will be most useful to you and your institution-if you are a healthcare worker-or your family-if you are a patient.
Sadly, some healthcare providers in the United States continue to reuse and misuse medical equipment, including syringes. Additional focus areas this year included reuse and misuse of single- and multi-dose vials of medication and responding to increasing reports of drug diversion among healthcare workers. Through the HONOResponse program, HONOReform is poised to help patients and communitities immediately following a patient notification or confirmed outbreak.
SOME GOALS FOR 2016
Thank you to our supporters for helping us work toward these goals:
To develop an education program, at no or reduced cost, on injection safety for healthcare workers and to work in tandem with colleagues to advance these and other infection prevention efforts.
To organize and help host a national meeting on drug diversion prevention and then to follow up on the action steps we adopt at the meeting to influence mitigation and elimination of the problem.
To continue to encourage international leaders to focus on making injection safety a priority.
“Its like trying to head off a bomb before it happens” – Drug Diversion Prevention
A recent report in GoLocalworcester.com raised concern about a recent series of arrests and convictions of healthcare workers in the Worcester, MA area related to stealing drugs.
In a compelling statement, David Schildmeier of the MA Nurses Association revealed the challenge of prevention of diversion of narcotics by healthcare providers: “It’s like trying to head off a bomb before something happens. Our view is that addiction is a disease and we try to address it to the best of our ability.”
We urge you to read the article in its entirety to get an overview of recent drug diversion cases in Massachusetts and a brief summary of what one organization is doing to prevent the problem. Here is the article: Drugs and Health Professionals in Worcester: Is This a Growing Problem?
Real fear in South Korea Hepatitis C outbreak
Prior to my 2009 Hep C infection I paid little, if any, attention to issues of safe injection practices, drug diversion or outbreaks. In my ordinary life, I had no concern for such things. In fact, I am not even sure I could adequately define any of those terms prior to the chaos of 2009 and the outbreak in Colorado.
But since, I have kept myself in the know, paying attention to trends, outbreaks and legislation to protect patients. My email inbox and social media accounts are littered with stories, mostly bad, about errors in patient care. I truly hope that some of the initiatives I have become a part of will put a stop to most of these incidents. However, in preparing for every situation in an attempt to prevent these events you will find a tale so far fetched you want to read the facts 2 or 3 times just to insure what you initially thought you heard was correct. Read more
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
Just Google “CDC Drug Diversion”
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.
Methodist Monday – Leah’s perspective
Leah Mittermeier, a Junior Level Nursing Student at Nebraska Methodist College, shares her perspectives on injection safety
Hearing Evelyn McKnight’s story really put into perspective what could go wrong if safe injection practices don’t take place. As a nurse I would feel so much shame in knowing my actions threatened people’s lives. I want to be as knowledgeable as possible with injections to ensure every patient I come in contact with is safe.
Being a patient safety advocate means speaking up anytime you see anything that could put a patient in danger. I know that it could be awkward confronting a colleague who was practicing unsafely, but at the end of the day, the patient’s safety and well being should come first. It is our responsibility as nurses to speak up for our patients. They might not realize that an unsafe practice is going on, so it is our responsibility to be on watch for anything threatening to the patient.
I’m very inspired to meet someone who had such a terrible experience and turn it into a learning opportunity for the world. I was impressed how calm Evelyn McKnight is after the experience and the fact that she doesn’t seem to hold grudges against the people involved.