Tag Archives: patient safety

Happy New Year!

January 5, 2015

Evelyn McKnight and Lauren Lollini

Welcome back to the HONOReform blog, aka “Survivor Stories,” for our second full year of publication. We thank everyone who has had a role in making our blog a growing success—contributors and readers and everyone who has suggested to friends that they should check out our blog and pass it on to others.
And we encourage you to please continue to support our efforts.
Here at HONOReform, community-building is a key to emphasizing safe injection practices and doing all we can to educate the public and reeducate providers on the absolute necessity of injection safety.
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Drug Diversion, a Broken Healthcare System

December 8, 2014

Evelyn McKnight and Lauren Lollini

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.

If you are a regular member to this blog you will have heard me say these things before, so I apologize for the repetition, but it appears I may not be saying it loud enough. So I am thankful to have the support of fellow patient safety advocates, healthcare workers who understand the broken system as well as a series of talented reporters to help articulate the point.

Our healthcare system is broken, let me say that again, it is broken and not the way the majority of Americans might think after reading that statement. It isn’t about the Affordable Care Act, in fact, just the opposite. It is underneath the polished floors and inside the magnificent facilities. It is behind the scenes, what happens when most people are not watching.
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It Takes Courage to Speak the Truth

September 29, 2014

Evelyn McKnight and Lauren Lollini

Lauren is the survivor of the 2009 Hepatitis C Outbreak in Colorado who chose to take a first step to passing legislation to make patients safer.

Lauren is the survivor of the 2009 Hepatitis C Outbreak in Colorado who chose to take a first step to passing legislation to make patients safer.

As a therapist, I often find myself congratulating clients for taking the first step as that is usually the most difficult. That first step might be making a phone call and asking about what resources are available for help or quite literally taking that first step into my office. So, too, do I congratulate the past contributors to our blog who have gone above and beyond to take that first step to share their stories. By speaking their truth, they have risked much, but were still undeterred.

You simply need to scroll back through the last few months and you will find many heroes who could no longer stay silent. Most recently, Anita Betrand shared her journey from addiction as a CRNA to that of an advocate speaking out so others can learn from her. Her struggle in and of itself was an arduous one, yet Anita chose to take that one next step to help educate so other healthcare workers finding themselves in a similar circumstance know there is a light at the end of the tunnel.
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Sharing stories, transforming ourselves

September 22, 2014

Evelyn McKnight and Lauren Lollini

Evelyn McKnight, president of HONOReform

Evelyn McKnight, president of HONOReform

In my work as a patient safety advocate, I have had the great good fortune of meeting many people who share with others their tragic story of how they were affected by unsafe healthcare. Like my family, their families were hit with a Mack truck on the road of life when they went to the doctor seeking better health, but came away with a worse medical condition because of unsafe healthcare. Telling the story may be gut-wrenching – it can be like living a nightmare all over. But through sharing their stories, these brave men and women are able to transform their experience into something useful, rather than simply a horrible personal trauma. read more »

Sharing stories, transforming healthcare

September 15, 2014

Evelyn McKnight and Lauren Lollini

“If I look at the mass I will never act. If I look at the one, I will.”
– Mother Theresa

Evelyn McKnight, president of HONOReform

Evelyn McKnight, president of HONOReform

Tomorrow marks the one year anniversary of “Survivor’s Stories” blog. We thank you for your loyal readership, and we ask you to share with all your associates.

Today we want to thank the many people who have so graciously shared their personal stories with us. Thank you Barbara, Johnny, Mary, Amanda, Ron, Tom, Kim, Tom, Chuck, Melisa, Patty, Tam, Jan, Sharon, Joe, Karen, Rich and Anita for sharing your own story of how your life has been affected by unsafe injections. We know how difficult it can be to share such deeply personal stories with others, especially total strangers. We also know how vitally important it is.

The number of Americans that have been affected by unsafe injections in the past decade is staggering, reaching into the hundreds of thousands. Yet these numbers, although alarming, do not bring about change as readily as the story of the one. These numbers are dry statistics, “human beings with the tears dried off,” and fail to spark emotion or feeling and thus fail to motivate action. Social psychologists argue that this reflects the way our consciences and ethical systems are based on individual stories and are distinct from the parts of our brains concerned with logic and rationality. See “Psychic Numbing and Genocide” for more fascinating information on the numbing effect of impersonal data.

It is the personal stories that change hearts. And when hearts are changed, behaviors are changed. Healthcare becomes safer for all Americans.

I will never forget my first visit to Capitol Hill to visit my congressional delegation’s offices. Congressmen are busy people, and the staff that supports them is equally busy. When I first sat down with staffers, I could read distraction and disinterest in their faces. But as I told my story, they became transformed. They peered at me closely. They asked questions. They took notes. And by the end of the interview, they asked me what their boss could do to help and even made offers of what he would do that day.

Personal stories are powerful. When there is a face on an issue, it becomes real. It moves people to action.

I was very nervous the first time I told my story publicly, which was to a nursing class at Johns Hopkins School of Nursing. After the class, the professor said to me, “Today you have spoken to a hundred new nurses. After hearing you speak, they will never compromise patient safety. Through your story, you have made healthcare safer for all the patients that they will serve, which will be thousands upon thousands over the course of their careers.” The butterflies in my stomach flew away immediately, and after looking at it in this way, I have never been reluctant to share my story ever since.

Do you have a story to tell?
How would hearing your story motivate providers, policymakers and manufacturers to commit to safe injections?

Again, we thank all the many people who have shared with others how their lives have been affected by unsafe injections. And we ask those of you who have a story, but have not shared it, to let us help you tell your story. Contact me anytime at evelyn@www.honoreform.org. Thank you.

Next week we will discuss how sharing stories help the people who have been affected by unsafe injections.

Making Lemonade: One CRNA’s Story of Addiction and Recovery – Part 1

August 11, 2014

Evelyn McKnight and Lauren Lollini

Anita Bertrand, CRNA, will be presenting at the upcoming AANA annual meeting

Anita Bertrand, CRNA, will be presenting at the upcoming AANA annual meeting

Anita Bertrand is a certified nurse anesthetist. She will be giving the 11th Annual Jan Stewart Memorial Lecture at the AANA 2014 Nurse Anesthesia Annual Congress
September 13-16, 2014 Orlando, Florida. We are grateful to her for sharing her story of addiction and recovery today and next week.

A recent report by the CDC identifies drug diversion in health care settings as the cause of potential exposure of blood-borne pathogens to nearly 30,000 Americans over a ten year period “Outbreaks of Infections Associated With Drug Diversion by US Health Care Personnel”. Drug diversion is commonly attributed to healthcare workers (HCW) who are addicted to drugs. In my experience as an addicted HCW, I understand how this inconceivable incidence can occur, although it seems incomprehensible that I could be the cause of such devastating harm to my patients, others and to myself. I also understand the impairment the disease of addiction causes to the HCW’s ability to make rational and safe decisions for both self and for patients under his or her care.

There are many unanswered questions and I don’t have all of the answers:
• How many HCWs are suffering from the disease of addiction/alcoholism and hiding in fear of the future, not getting treatment and/or have no access to treatment upon discovery?
• How many of my colleagues are practicing and do not recognize or are willing to admit they are chemically dependent?
• How many HCW recognize the dependency and have no idea what to do?
• How many families, friends and employers suspect a problem and don’t know what to do to help?
• Can helping addicted HCWs contribute to drug diversion prevention and lessen the risk to patients?

Addiction is a disease, not a choice.
My experience as a HCW with an addiction to opioids has demonstrated that I did not, and do not have, control over my behavior when actively using. The disease had taken over my thinking and decision making capabilities when it comes to the use of, and administering of drugs to patients.

My behavior was incomprehensible, both in terms of what I did in order to obtain the drug of addiction as well as in the manner in which I took care of patients. The harm caused to patients by HCWs is both direct and indirect, in the lack of care, provided by the HCW and in the inability to be cognizant of the care provided. The HCW active in the disease of addiction is constantly focused on when and how to obtain/divert the next drug, thereby not focused on the patient and his/her needs or care. I understand how unsafe injection practices occur when addicted HCW are not identified and treated. I also understand how the disease continues to progress to more and more risky behavior for both patient and provider when action is not taken to arrest the disease.

There are many limitations to identifying HCWs with the disease of addiction. My disease was permitted to progress for many months as I became more careless and harmful to both myself and patients under my care. In the end I was grateful to have been discovered, for I realize today that the fear and shame would have carried me to my death.

Stigma of Addiction
Fear and shame are the emotions that isolated me. Even though I knew how to find support and treatment, the tremendous fear and shame of being identified and removed from the workplace in order to get treatment paralyzed me. I knew the insurmountable stigma of this disease would follow me, in terms of my license and career.

The disease of addiction/alcoholism causes abhorrent and sometimes, criminal behavior. Discovered in active addiction/alcoholism, HCWs are commonly terminated. Removal from the workplace is the only appropriate action for both patient and provider safety. But with termination, they are left without a means for the desperately needed treatment for the disease. When HCWs have a stroke, a heart attack, are diagnosed with cancer, or a hyper/hypoglycemic crisis, they are removed from the work environment, encouraged and supported in treatment for their disease, and permitted in most cases to return to the work when their disease is stable or in remission. Additionally, it is common that friends and colleagues go to great lengths to assist the HCW by covering shifts, providing meals for the family, and even giving up PTO time to help the HCW in financial crisis due to their disease.

Compared with other disease conditions, support for the addicted HCW is in short supply. Lack of knowledge and understanding of the disease, stigma, and misjudgment prohibits others from being helpful. The recent USA Today piece, “Doctors, Medical Staff on Drugs Put Patients at Risk” covered some of my story. But, there is much more to say. My husband was left with a two year old, starting a new job and having no immediate family in the city while I went off to treatment 1000+ miles away for 18 weeks. Where were all our friends? Where were all the colleagues I’d worked with all those years? Nobody brought over a casserole or offered to babysit so he could have a break and take care of himself. The inability to ask for help extends to the families, who also face the stigma and shame surrounding this disease. Addiction and alcoholism impacts everyone who cares and knows the HCW.

This stigma only perpetuates the disease, the denial, and the ability to obtain lifesaving treatment. That fear, shame, and stigma prevented me from asking for help early in my disease when I had a moment of clarity. It prevented my husband from understanding the depth of the problem so that he could seek help for me.

Next week, Anita continues her story of addiction and recovery.

“Doing all I can to protect patients”

August 4, 2014

Evelyn McKnight and Lauren Lollini

A St. Louis nurse, fearful for the welfare of her patients, facilitated a necessary change in procedure. This is her story.

OSHA regulations protect healthcare workers in the workplace

OSHA regulations protect healthcare workers in the workplace

Recently, OSHA issued a citation against SSM Healthcare, located in the St. Louis Missouri metropolitan area. The SSM Health Care system was fined because of safety violations that potentially exposed healthcare providers to bloodborne pathogens.

Here is a link to a recent article, in which the situation is fully explained:


Unfortunately, health fair participants were put at risk. But OSHA only deals with employee safety.  An investigation by the Joint Commission is ongoing; however, those results may not necessarily be made public. It is unknown at this time if the local or state health departments or the CDC will become involved.

I am grateful for the support of representatives of HONOReform, who listened to and validated my concerns and referred me to additional resources at the CDC and the FDA.

I tried my best to facilitate change within the healthcare system. Although many people at the healthcare system were provided with the most up to date information and some changes were made incrementally, not all policies and procedures were brought up to necessary standards.

If you have been to a mass health screening that included point-of-care blood testing you that was conducted by the SSM Healthcare System in the St. Louis area, you may call 877-759-5575 option 2. This phone number is for only those who attended a Health Fair sponsored by SSM. All others who are concerned about past exposures may want to contact your Primary Care Provider for further evaluation.

The greatest risk of exposure from these types of events is exposure to Hepatitis B (because of it virulence). Additionally, HIV and Hepatitis C are blood borne pathogens that one needs to be concerned with as well.

All shared glucometers and cholesterol-lipid meters should be disinfected with a hospital grade disinfectant and allowed to air dry for two minutes or as recommended by the manufacturer of the disinfecting agent. Additionally, body fat analyzers, if handled by those who had a finger-stick and may have blood on their fingers/hands, should be disinfected as well.

In an upcoming blog post here at HONOReform, I will explore these standards, which come right out of the information provided to us by CDC, in more depth.

We are not trying to embarrass anyone, nor cause undue worry. However, for peace of mind and in order to get prompt medical care if exposures have occurred, participants of previous health fairs or mass health screenings should be tested for bloodborne pathogens. I encourage these patients to be tested.

Also, I am recommending that health fairs that include point-of-care blood testing be suspended until they are fully evaluated. Perhaps health fairs that include point-of-care blood testing should be eliminated due to the large number of outbreaks linked to shared glucometers and other unsafe practices such as shared lancet devices?

Avoiding risk to patients—always being mindful of what we are doing, and following the guidelines that have been established for us—is so important.

Even though it was not easy, I am glad that I made the decision to do all I can to implement these standards and protect our patients.

Join me to get the message out: Reuse of syringes must stop TODAY!

July 14, 2014

Evelyn McKnight and Lauren Lollini

Rich Caizza is a safety syringe engineer and an HONOReform board member living in New Jersey

Rich Caizza is a safety syringe engineer and an HONOReform board member living in New Jersey

Hello, my name is Rich Caizza and I live in New Jersey. I’d like to share with you my personal experience as a patient having to deal with a dentist who had been re-using needles and syringes in his practice. A little background about myself before that day. read more »

Lauren Lollini Salutes Joe Perz and the CDC DHQP

Joseph Perz, DrPH, MA Quality Standards and Safety Team Leader for the Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention

Joseph Perz, DrPH, MA
Quality Standards and Safety Team Leader
for the Division of Healthcare Quality Promotion,
Centers for Disease Control and Prevention

I have held a special place in my heart for Dr. Joe Perz of the CDC for the last 5 years. Even though we have not met in person, we were introduced in a very peculiar way. You see, Joe was one of the first on the scene to investigate a potential outbreak in Colorado in the spring of 2009. The CDC was called in when it was determined there were two reported cases of hepatitis C from individuals who had surgeries at the same hospital just a day or two apart.

I was one of those two patients. I am eternally grateful to Joe and his colleagues for not only getting to the heart of the outbreak and allowing a broken system to be mended but for offering me a sense of understanding about how I had gotten infected. Along the way, several other healthcare professionals with whom I was in contact scoffed at my insistence that I had been infected during my healthcare procedure—and that many other patients had, too. Ever since this first unusual “meeting,” I have followed the tremendous work of Joe Perz and the CDC’s extraordinary Division of Healthcare Quality Promotion (DHQP). I’m a fan!
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A special thanks to our colleague, Sharon Bradley

May 11, 2014

Evelyn McKnight and Lauren Lollini

Sharon Bradley, RN CIC, of the Pennsylvania Patient Safety Authority.

Sharon Bradley, RN CIC, of the Pennsylvania Patient Safety Authority.

We are just two of many citizens and patient advocates who remain concerned about the safety of our nation’s many outpatient clinics—and ambulatory surgery facilities, in particular. Perhaps, it is because trips to these type of healthcare settings resulted in the Hepatitis C virus for both of us.

Since the founding of HONOReform in 2007, there has been a migration of care from the hospital to the outpatient setting. Very few of us do not know someone who described their surgery or procedure, which appeared quite complicated, yet they were released the same day.
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