In this piece, spurred on by the maelstrom of events which surrounded the arrest of a surgical tech from Swedish Medical Center the previous month, Osher and Olinger point out the simple truth that hospitals do not all prescribe to the same standard of safety and precaution when a drug diversion occurs. It was made clear that simply not reporting a theft, leaves open the possibility of hiring of these drug diverting healthcare workers at other facilities and allow them to continue their diverting ways. These reporters did an extensive job in reviewing state health department, licensing board and police records. And the results were unbelievable. Read more
Over the past few months, the news has been riddled with stories of a surgical tech who diverted drugs in 4 states. He was finally caught in Colorado when a fellow employee finally turned him in. But the question remains, how did he go from a Navy court martial to wreaking havoc across multiple states and several hospitals?
We hear more about drug diversion, especially over the last decade, because we are catching more diverters. Kim New, executive director of the International Health Facility Diversion Association, states that “diversion almost certainly occurs at every institution that handles controlled substances, and the rate of discovery of diversion events has increased steadily over the past decade. “ And while most facilities have certain protocols in place, there is no formal set of rules to govern all, so there remains lots of gray areas which allow employees to slip through the cracks. Read more
This past week we learned that there was another incident of drug diversion at Swedish Medical Center in Englewood, Colorado. This is not far from Rose Medical Center in Denver, the site of the 2009 drug diversion event which caused 19 patients to be infected with Hepatitis C. So if this seems eerily familiar, you are right, it is.
At last report, no exposure to any infectious diseases have been reported. My sincere hope is this remains to be the truth for the almost 3000 patients who were notified that they may have been put at risk.
But the cold hard facts remain. There was another drug diversion at an HCA hospital, the same hospital system which includes Rose Medical Center. And I am sure the most asked question is going to be “Why?” Why were there not better systems put into place to safeguard again this? Why did we not learn from the mistakes made in 2009?
We ask why because we know this was a completely preventable event. We ask why because despite any reliable data about the frequency of drug diversion in healthcare facilities, primarily due to the covert nature of this crime, we know it is always a possibility, always a risk. We ask why because there are many hospital systems who have successfully been able to monitor, assess and prevent drug diversion incidents.
So while my thoughts remain with those 3000 patients and their families and friends as they await news of their blood tests, I find comfort in knowing behind the scenes the Colorado Department of Public Health and Environment is doing what needs to be done to investigate, educate and keep the risks at a minimum. With the help of the CDPHE’s One and Only Campaign, awareness is being raised among patients and healthcare providers regarding safe injection practices. Or if more information is needed, please contact HONOReform at www.honoreform.org.
Below you will find a guest commentary which appeared in the Denver Post this past Saturday offering solutions for the future.
Swedish Medical Center infection scare didn’t have to happen – The Denver Post
I am grateful HONOReform had the opportunity to respond in the June 12 Concord Monitor to the horrible but all too common report of provider drug diversion by a healthcare worker.
As Steve Langan, HONOReform executive director, said, “Drug diversion may likely be the most enormous elephant in the room, in healthcare.” Anyone who has tried to pay attention to the many conversations on healthcare in the United States knows that there are many gaps and there have been many breakdowns.
If we continue to look the other way and deny and ignore the fact of widespread drug abuse and drug diversion among healthcare workers, more and more systematic challenges will develop.
According to recent statistics, there are as many as 379,000 addicted healthcare workers right now in the United States.
What does this mean for patients? They may not be receiving the medication they have been prescribed, in the recovery room or in other hospital settings. And, worse yet, they may receive an infection of bloodborne pathogens, such as hepatitis C or HIV.
At HONOReform, we believe a first priority in American healthcare is protocol and regulations that prevent drug diversion. This is a problem that can and must be fixed.
Robust materials developed by partners at the Safe Injection Practices Coalition the One and Only Campaign will soon be in place. We welcome the opportunity to help distribute these materials to leadership at healthcare facilities throughout the country.
Messaging and education are essential, important; but, in this case, we need government leaders at all levels to take a stand. Patients have been placed over and over in a vulnerable position, and addicted healthcare workers continue to practice with very little oversight and not nearly enough intervention.
In the near future, we will make an announcement of an upcoming meeting on drug diversion prevention.
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!
May is National Hepatitis Awareness month and this year the CDC is designating May 19th as National Hepatitis testing day. This is an excellent reminder for the healthcare community and others to get tested.
Not me, you say? Let me tell you why ignoring this might be a deadly mistake. According to the CDC over 4 million people in the US have chronic hepatitis C and most have no idea. Many of our baby boomers are infected and because they show no symptoms, they are clueless to the infection and the damage it is doing to their bodies. http://www.cdc.gov/hepatitis/TestingDay/index.htm
Possible Hepatitis, HIV Exposures in Santa Barbara, CA
My heart skipped a few beats last week when I read about the potential outbreak resulting from a lack of safe infection control measures in a doctor’s office in Santa Barbara County. Things had been going fairly smoothly in regard to safe injection practices. In 2014, none of the investigations which took place found any disease transmissions. In fact, we had not had an investigation over the last six months and although we never stop educating and spreading awareness, we were able to breathe a small sigh of relief. Read more
Celebrating the Success of the Partnership for Patients
Recently, Partnership for Patients (PfP) issued a report on its achievements. You will recall from a previous post that the PfP is a very large national quality improvement learning collaborative with two aims: to improve safety in acute care hospitals and to improve coordination of care at discharge to prevent readmissions. The PfP is a public-private partnership that seeks national change by setting clear aims, aligning and engaging multiple Federal partners and programs, aligning and engaging multiple private partners and payers, and establishing a national learning network available to all healthcare providers and facilities.
I participated as a patient advocate in the work of the PfP. My fellow patient advocates and I were invited to give input in every meeting, every phone call, every critical decision. The patient advocates imbued passion for safety into the conversation. This passion set the tone for co-operation and action among the members of the campaign. Several times I was part of a discussion which bogged down in, what seemed to me, a standoff between two camps: those who believed that a proposed policy would save lives and thus should be adopted, and those who believed that the policy was too difficult and/or costly for hospitals to execute. A patient advocate took to the airwaves, and gave her personal story of the harm that she suffered because the policy was not in place. The tone immediately changed from “this is too difficult/costly to achieve” to “we must do whatever we can to keep patients safe.” Within minutes the team moved forward, working co-operatively for patient safety. I believe the patient’s voice was a major contribution to the overall success of the campaign.
The Partnership for Patients and its over 3,700 participating hospitals were focused on making hospital care safer, more reliable, and less costly through the achievement of two goals:
Making Care Safer. By the end of 2014, preventable hospital-acquired conditions would decrease by 40% compared to 2010.
Improving Care Transitions. By the end of 2014, preventable complications during a transition from one care setting to another would be decreased so that all hospital readmissions would be reduced by 20% compared to 2010.
As part of the PfP campaign, baseline measures were collected on nine hospital-acquired conditions (e.g., adverse drug events, pressure ulcers and surgical site infections) in 2010. At the end of the initial engagement period of the PfP, a cumulative total of 1.3 million fewer hospital-acquired conditions (HACs) were experienced by hospital patients over the 3 years (2011, 2012, 2013) relative to the number of HACs that would have occurred if rates had remained steady at the 2010 level. It is estimated that approximately 50,000 fewer patients died in the hospital as a result of the reduction in HACs, and approximately $12 billion in health care costs were saved from 2010 to 2013.
It was so gratifying to be part of this effort that keeps the patient at the center of health care quality improvement. The momentum that was created through the PfP is exciting, and I look forward to the continuation of the patient safety movement that is driven by the patient voice.
Saluting the Healthcare Professionals at Madigan Army Medical Center
We were so honored recently to be asked to give several presentations to healthcare providers at Madigan Army Medical Center near Tacoma, Washington.
I have always been in awe of the brave men and women in military service. The commitment and sacrifice that they make is beyond measure. To volunteer to serve our country, often in dangerous circumstances and far away from loved ones, is incredible. They have my deepest admiration.
So it was great respect that we gave presentations on patient safety to healthcare personnel. And our respect was well deserved. The healthcare providers asked thoughtful questions about patient safety and shared their own, impressive efforts in insuring that soldiers receive safe, quality healthcare.
Here is a 3 minute video tribute to Madigan. Madigan Army Medical Center, we salute you!
On March 3rd, the India Times reported an incident where 59 children were injected with the same syringe and needle while being administered an antibiotic. This not only highlights the many issues surrounding the state-run hospitals there, but also illustrates the point we, at HONOReform, have been helping to bring to light.