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Patient Safety Awareness Week

Patient Safety Awareness Week

Patient Safety Awareness Week
This is national Patient Safety Awareness Week

This week is National Patient Safety Awareness week. It is a good time to reflect on patient safety in the United States.  We can all work together to improve awarenss of the need for improved patient safety.

There are many estimates about how many people are harmed through preventable medical error each year. Estimates suggest that about 100,000 to 440,000 people die per year from preventable medical error each year. Many more sustain harm that was significant but not fatal.

One life destroyed by medical error is one too many. But these numbers suggest that annually hundreds of thousands of people have their lives destroyed by preventable medical error. These numbers represent real lives of real people. We are all patients. We are all at risk for suffering caused by healthcare. We must take action to save ourselves and those we love from harm sustained through healthcare.

In my home state, we have the means to examine adverse events and educate for prevention through the Nebraska Coalition fo Patient Safety (NCPS). NCPS collects voluntary reports of suspected medical error from medical facilities. It aggregates the data to develop feedback, training and education about causes of medical error and shares the learning with member facilities. Members receive feedback on events, root cause analysis support, information and evidence-based best practices, and patient safety culture development.

However, when the NCPS was established in 2005, a consistent vehicle for funding was not established. The Coalition depends upon voluntary membership dues; this limited and uncertain budget hampers NCPS reach and effectiveness.

Last month, I jumped at an opportunity to increase patient safety in Nebraska by working on legislation to create consistent funding for NCPS. A bill to provide additional fees to some licensed healthcare providers to create the Patient Safety Cash Fund was introduced as LB1127. If passed, $10 will be collected per year from licensed  physicians, nurses, pharmacists, occupational and physical therapists to create the Patient Safety Cash Fund. This fund would go directly to the Nebraska Coalition for Patient Safety.

If LB 1127 is enacted, the Coalition will:

  • expand their work from hospitals only to the continuum of care;
  • engage all healthcare stakeholders, regardless of their position on the current bill, to conduct a patient safety needs assessment, develop a strategy to address cross-cutting priority needs, and then evaluate the effectiveness of our efforts;
  • hire additional staff with knowledge and skills in clinical care, informatics, human factors, and organizational culture to receive the increased volume of reports and aggregate and analyze them (while reserving funds for office space, computers, software, and web support);
  • implement a communication plan to provide feedback to healthcare professionals and the public using aggregate data to describe the patient safety hazards we identify and the resources needed to address them; and
  • expand efforts to ensure all healthcare professionals have the language and tools needed to advocate for patients.

In summary, LB 1127 has the power to engage all healthcare professionals in Nebraska in our most important priority…keeping patients safe while receiving care that is intended to help them.

I’m pleased to report that the Health and Human Services Committee held an executive session and voted to advance patient safety bill LB 1127 to General File! We will continue to work with other committed organizations like the Nebraska Medical Association and the Nebraska Hospital Association to pass the bill and increase patient safety!


Drug diversion exposes patients to disease

Drug diversion in the Operating Room

Drug diversion exposes patients to disease
Drug diversion in the Operating Room is a serious problem

How much harm can a single drug diversion actually cause your facility? All it takes is one stolen or tampered syringe to cause a potential outbreak. Without a watchful eye, entire health care facilities are at risk of exposure.

For example, one diverting surgical technician put 5,900 patients at risk due to their carelessness. Not only did they expose patients to the disease, they also used fentanyl syringes for self-use. It led to 19 confirmed cases of Hepatitis C, and the diverting surgical technician now faces 30 years in prison.

In a separate outbreak instance, another surgical technician potentially exposed 2,900 patients to Hepatitis B, Hepatitis C, and even HIV infection. 2 people tested positive for hepatitis as a result. This surgical technician faces charges of tampering and obtaining fentanyl by deceit.

Lesson learned: all it takes is one irresponsible surgical technician to cause a scare or outbreak. Patient safety is of the utmost importance — keep a watchful eye on any syringes in use. All it takes is one surgical technician to steal a syringe to compromise an entire facility. Check out the infographic below from Diversion Central by Omnicell for more information.

Omnicell Technologies and Solutions

Preventing the Unthinkable


Healthcare providers in all types of settings have reviewed and followed safe medical injection best practices. Nonetheless, contamination—the “unthinkable”—still happens.

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.*

In 2000-2001 a cancer clinic in Fremont, Nebraska caused the worst hepatitis outbreak in US history. During chemotherapy treatments, 857 patients who were already waging the fights of their lives against cancer, were inexplicably exposed to the deadly, blood-borne hepatitis C virus. At least ninety-nine of them contracted the lethal illness. The horror was unprecedented—this was the largest healthcare-transmitted outbreak of hepatitis C in American history.

I am a survivor of this outbreak and chose to use the money from my settlement against the oncology clinic to co-found the patient advocacy foundation HONOReform. We are now excited to offer the Free Injection Safety Education for Healthcare Providers and Consumers Program, which aims to leverage our story to help prevent other outbreaks.

The program is delivered by myself and my husband, Tom McKnight, a family physician who helped uncover the Nebraska outbreak. It outlines our own story of infection attributed to reuse of syringes in a medical setting. We also examine factors contributing to the Fremont outbreak and make recommendations for prevention.

The continuing education presentation is offered at low or no cost to organizations sponsoring continuing education activities for healthcare professionals or consumer-focused activities.

Learn more about the programs offered for:

To receive more information or learn about the options that might work for your organization, simply provide your email on the form here.

This work began as a response to an unthinkable, preventable tragedy. By building safeguards into the injection process, incentivizing health care providers at all levels to universally follow fundamental safety standards, and educating and reeducating providers, all patients will be protected all the time. Future tragedies can be avoided.


By Evelyn McKnight



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