When will we learn from past mistakes?

July 21, 2014

Evelyn McKnight and Lauren Lollini

Lauren is one of many Coloradans infected with Hepatitis C from a hospital outbreak in 2009.

Lauren is one of many Coloradans infected with Hepatitis C from a hospital outbreak in 2009.

On July 12th, the New York Post printed an article about some very disturbing issues at a VA facility in Albany. The article illustrates just how bad things can get in a hospital setting. These reports are atrocious.


But what continues to replay in my mind is the section which outlines a nurse diverting morphine. Apparently, this nurse was withdrawing the pain medication from vials and replacing it with a clear unknown substance. Could have be water or saline. The article states that over the past year this could have occurred more than 5,000 times.

Some 5000 opportunities for patients to go without their pain medication. Some 5000 opportunities to recognize this nurse’s actions and put a stop to it. And countless other patients and hospital employees put at risk.

This is not a new story, I am afraid. The news continues to be riddled with these incidents. The saddest part is we are not learning from past mistakes. Hospitals and healthcare facilities are not keeping their patients safe. They are not taking the advice of those who have gone before them. They are not tightening up their systems before an incident occurs. They are not heeding the practical advice from professionals who have outlined policies and procedures to stop these drug diversions from happening.

I ask, if not now, when?

5 and half years ago, I did not even fully understand what the term drug diversion meant. Now I am doing everything in my power to make sure we are not only educating on it’s meaning, but also preventing it’s occurrence. As many of our readers know, I am one of many patients throughout the United States who have been infected with Hepatitis C while in a healthcare facility. My story is strikingly similar to the methods used by the nurse at this Albany VA hospital.

Since the outbreak in 2009 which infected me and 2 dozen others, multiple incidents of drug diversion have taken place. Just last month, I applauded Joe Perz from the CDC for his tremendous work in bringing awareness to this crucial issue. And also why HONOReform has established a Drug Diversion Prevention Committee that includes patient advocates, health professional organizations, and health department representatives working to strengthen programs designed to prevent hepatitis outbreaks associated with drug diversion in healthcare settings.

I wish we could have worked faster. I wish the proposed changes had already taken effect. As these incidents continue to occur, I am afraid it will only get worse.

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