A Never Event

Announcing a new injection safety continuing education program



The Healthcare Learning Activitity Grant Program provides a quality continuing education presentation at low or no cost. HONOReform will provide a grant to organizations sponsoring


continuing education activities for healthcare professionals or consumer-focused activities.

Attendees will receive a flash drive containing the PowerPoint presentation, resources for injection safety, and the award-winning book: A Never Event: Exposing the Largest OUtbreak of Hepatitis C in American Healthcare History.

Description of Offered Programs
Healthcare providers in all types of settings have reviewed and followed safe injection best practices. Nonetheless, the “unthinkable” still happens, with significant impact on the patient and providers. The CDC estimates that there have been more than 50 outbreaks of Hepatitis C and/or Hepatitis B in the past decade due to reused needles, syringes or medication vials. Evelyn and Tom McKnight, founders of HONOReform, will share their own compelling story of infection attributed to reuse of syringes in a medical setting. Additionally, the McKnights will examine factors contributing to the outbreak and make recommendations for prevention.

1. “A Never Event – Don’t let it Happen in your Facility!”
A survivor describes a Nebraska “Never Event” in which 99 patients contracted Hepatitis C when a nurse reused syringes during chemotherapy administration. Root causes of the outbreak are examined as well as resources for prevention.

2. “Preventing Healthcare Transmission of Disease through injection Safety”
This presentation examines causes of patient-to-patient, patient-to-provider and provider-to-patient transmission of disease and offers resources for prevention.

3. “Injection Safety in Dental Practice”
Since 2012 thousands of patients have been put at significant risk of acquiring infectious disease from dental practices in four states. In one instance, the Colorado Department of Health notified 8000 patients that they were at risk for contracting Hepatitis B, Hepatitis C and HIV because their dentist’s practice reused needles and syringes. The McKnights will examine factors contributing to the outbreak and make recommendations for prevention in dental offices.

4. “Becoming an Empowered Patient”
Patients are learning that to receive the best quality healthcare, they need to effectively partner with their healthcare provider. A physician and a survivor of medical error discuss their own personal experiences of patient empowerment and ways to improve the physician-patient partnership.

For more information and to apply, go to Learning Activitiy Program


It is my honor to highly recommend Dr. Evelyn V. McKnight as a speaker. I can think of no one better to present this information. Without a doubt, she exemplifies the motivation and goal-directed approach, in concert with the knowledge and passion to deliver this complex issue. Wanda O. Wilson, PHD MSN, CRNA, Executive Director, American Association of Nurse Anesthetists

Evelyn tells her story with compassion and purpose with the intention to educate listeners about the egregious unsafe practices that continue unabated in healthcare practice sites. I enthusiastically recommend Evelyn McKnight to any group seeking to educate and inspire its members! Janice M. O’Dowd, Certified Continuing Medical Education Professional, Kent Hospital, Warwick, Rhode Island

The McKnights put together an extensive slide show presentation, with multiple resources for further education. They provided tools for healthcare providers to use in their jobs to help educate other providers and present healthcare associated infections. … If you are looking for an engaging educational presentation for your next healthcare conference, I would recommend Tom and Evelyn McKnight. They were very well received, and did a wonderful job. Michele Maryanski, RN CIC, APIC New England Program Director

Our feedback following this course was absolutely outstanding! We hope that Evelyn will continue to educate the public and bring more awareness on safe injection practices so an event like this never happens again. Melissa Adams, Continuing Education Director, AZ Perio Dental Hygiene Study Club



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!

Methodist Monday – Preparing nurses to advocate for their patients

Nursing school faculty at the NE Methodist College stress patient advocacy in their curriculum
Nursing school faculty at the NE Methodist College stress patient advocacy in their curriculum

The American Association of Colleges of Nursing emphasizes that an essential component of baccalaureate nursing education is to prepare the graduate to advocate for individuals, families, groups, communities, populations, the profession of nursing, and changes in the health care system (AACN, 2008). The challenge for nurse educators is how to define advocacy, not just as a word but a greater concept, and how to engage students in advocacy.

Patient lived experiences are a great way for students to understand how their actions in their own practice affect their patient at the time of care and in the future. The focus of nursing education is to prepare students to understand their patient’s problem and provide action steps to correct the problem. The use of personal stories helps the students to visualize and truly understand how their interventions and rationale can affect their patients in years to come.

Reading the book, A Never Event, has made a huge impact on our nursing students. Reading about an incident that happened so close to home allows the students to take accountability and ownership for these profound issues in our health system. The shocking events that occurred call the students to become advocates for quality and safety improvement for our patients. They identify with the stories and the characters and become empowered for change.

Evelyn McKnight’s presence in the classroom helps students to see a person who has a passion for the cause of patient safety.  Evelyn is able to clearly articulate her mission for safe care for every person and she empowers students to see themselves as advocates for her cause as well.  She puts the concept of patient safety right onto the shoulders of the students as future competent health care providers.  I think students comprehend their responsibility for safe patient care in a whole new light after listening to Evelyn McKnight. After hearing her story and learning about all the ways she is impacting health care policy, students see that every person can make a difference in the world.

Evelyn’s contribution to a new book, The Truth About Big Medicine, compliments her personal story in A Never Event and expands on the issues of health policy in America. Evelyn gives a face and story to health policy, helping individuals better understand the importance of health policy awareness, advocacy, and activism. We look forward to including The Truth About Big Medicine in our nursing curriculum at Nebraska Methodist College.

Cathy Barnes, MSN, RN, Katie Doty, MSN, RN, Casey Frost, MSN, RN, Jodi Jenson-Bassett, MSN, RN, Carissa Nielsen, MSN, RN, and Echo Perlman MSN, RN are nursing faculty at the Nebraska Methodist College and the authors of this blog.


American Association of Colleges of Nursing. (2008). The essentials of baccalaureate education for professional nursing practice. Retrieved from http://www.aacn.nche.edu/education-resources/BaccEssentials08.pdf

Methodist Mondays: A Debut, from Nursing Student Matthew Sobczyk

Matthew Sobczyk is a nursing student at Nebraska Methodist College and posts the first 'Methodists Mondays' blog.
Matthew Sobczyk is a nursing student at Nebraska Methodist College and posts the first ‘Methodist Mondays’ blog.

At Nebraska Methodist College, the book A Never Event (McKnight & Bennington, 2010) is required reading at the junior level of the BSN nursing program. This past semester, Evelyn McKnight and Steve Langan visited the nursing classroom with a question and answer session regarding A Never Event and HONOReform. “Survivor Stories” will feature students’ reflections on the importance of Evelyn sharing her story and the work of HONOReform on their future nursing practice in a series called ‘Methodist Mondays’.

“Education and awareness are the cornerstone of the HONOReform mission. Lauren and I are grateful to Matthew Sobczyk, a nursing student, for providing this debut Methodist Monday blog,” Evelyn says.

During Dr. McKnight’s visit, I was very impressed with the amount of passion that she had for preventing reuse of needles, and enabling safe injection practices to prevent any further outbreaks from occurring. As a student nurse, I feel that enacting safe infection practices is one of the most crucial to prevent transmission of blood borne pathogens from patient to patient. Since needles are used every day for a multitude of reasons, it is important that no needle is used more than once to prevent any possible pathogens from passing between patients. It is one of the simplest acts that we as healthcare providers can use for safe practice. Hearing Dr. McKnight tell her story made me more passionate than ever to commit to this practice.

To be a patient advocate means to not only stand up for the patient and what their wishes are about the care that they will be receiving, it also means intervening when you see unwanted harm coming to your patient or any other patient from a fellow provider. I feel that being a patient safety advocate is one of the most important qualities of a health care professional, and if you can’t stand up for your patient and be there for them then you don’t deserve to be in the profession. You have to be there for your patient in order to provide the best possible care.

Without a doubt, I can’t thank Dr. McKnight enough for coming to speak to our class and sharing her story and her experience. When I had read her book, I was beyond shocked that such a horrific experience had taken place here in Nebraska, let alone in a town not far from Omaha. I also want to thank Steve Langan for coming along and talking about the activities that HONOReform has been a part of. It truly means a lot to have taken the time to come share their personal account with us. I won’t ever forget this experience.