Survivor Stories Blog
Medical Xpress, a publication of the Society for Healthcare Epidemiology of America, recently reported a cluster outbreak of Serratia marcescens, a gram-negative bacteria, due to drug diversion through tampering of syringes
The enlightening article describes how drug diversion through syringe tampering happens, its ramifications (including loss of life), and efforts to prevent it.
Drug diversion by healthcare workers is a growing problem in the United States. We must learn from outbreaks such as this if we hope to prevent others from happening.
The article is reprinted here in its entirety.
Narcotics diversion results in outbreak of serratia marcescens bacteria
July 6, 2017 in Medicine & Health / Diseases, Conditions, Syndromes
An illegal diversion of opioids by a hospital nurse tampering with syringes was responsible for a cluster outbreak of Serratia marcescens, a gram-negative bacteria, according to research published online today in Infection Control & Hospital Epidemiology, the journal of the Society for Healthcare Epidemiology of America. Five patients admitted to five different hospital wards within University Hospital in Madison, Wisconsin developed identical bacteria strains. Upon investigation, hospital epidemiologists linked the cases with the tampered syringes, the nurse was immediately terminated, and no further S. marcescens cases were identified.
“This incident sadly adds to the handful of healthcare-associated bacterial outbreaks related to drug diversion by a healthcare professional,” said Nasia Safdar, MD, PhD, senior author and hospital epidemiologist at the University Hospital in Madison, Wisconsin. “Our experience highlights the importance of active monitoring systems to prevent hospital-related drug diversion, and to consider this potential mechanism of infection when investigating healthcare-associated outbreaks related to gram-negative bacteria.”
Hospital staff first identified four hydromorphone and six morphine syringes in an automated medication dispensing cabinet that had been tampered with. This discovery occurred almost immediately after detection of the S. marcescens outbreak, prompting a controlled substance diversion investigation (CSDI) by key hospital staff.
Hospital epidemiologists conducted a review of blood cultures and molecular fingerprinting to identify the origin of the S. marcescens outbreak, concluding the possible connection between the cluster of infections and the narcotic diversion. Further analysis suggested four of the five exposed patients had contracted S. marcescens during a short-term post-operative stay in the Post-Anesthesia Care Unit, where the nurse worked. The fifth patient, who was the nurse’s father, had been exposed to the bacteria prior to his admittance.
The investigation found that the suspected nurse had accessed the medication cabinets where the tampered medication was stored. Testing of the tampered syringes suggested the nurse had replaced the active medication within the syringes with a saline or other solution, likely causing the S. marcescens outbreak. Four of the five patients recovered, while one died from Serratia sepsis infection.
As a result of the outbreak, the hospital team implemented additional diversion detection and security enhancements including tamper-evident packaging and installation of security cameras.
More information: Leah M. Schuppener et al, Serratia marcescens Bacteremia: Nosocomial Cluster Following Narcotic Diversion, Infection Control & Hospital Epidemiology (2017). DOI: 10.1017/ice.2017.137
Provided by Society for Healthcare Epidemiology of America
“Narcotics diversion results in outbreak of serratia marcescens bacteria” July 6, 2017 https://medicalxpress.com/news/2017-07-narcotics-diversion-results-outbreak-serratia.html
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.
Thank you for your interest in the work of HONOReform – the only organization dedicated to advancing injection safety. I am asking today for your support of our life-saving work.
Why do we advocate for injection safety?
You will be interested in this story about what happened in my family practice clinic recently that illustrates why we must – together – continue educating healthcare providers and patients about the critical need for injection safety.
My clinic scheduled an assessment by the CDC Nebraska Infection Control Assessment program team. These hard-working nurses and infection preventionists spent a day assessing our clinic’s policies and procedures, making sure that we are doing everything we can to prevent our patients from contracting disease while in our office.
At the end of the day, the assessment team sat down with us to give us their report. Fortunately, we are doing most things right.
But there was one thing that needed improvement. The team found an opened, unlabeled vial of lidocaine in a patient care area. Since the vial had not been disposed of properly, there was a risk that it could be reused improperly, potentially spreading disease.
How do we advance injection safety?
You probaby know that my wife contracted Hepatitis C through unsafe injection practices sixteen years ago. Since then, it is my personal crusade to educate about injection safety. I preach to doctors, nurses and medical students that it is never okay to reuse syringes, needles, medication vials or other medical equipment intended for one time use. But despite my efforts, an unsafe injection could have taken place, even in my own office. In 2016, HONOReform gave educational presentations to 2208 people as well as reaching thousands through social media and virtual audiences. Everyone who has been touched by the retelling of our story joins me in thanking you for your generous partnership and support. We are committed to educating about and advocating for injection safety with every possible opportunity, to keep you and your family safe when you access healthcare.
But even with all our efforts to educate about injection safety, there were eight outbreak investigations of disease transmission through unsafe injection practices in 2016, affecting thousands of Americans! Together we must work even harder to advance injection safety.
Here is how you can spread the word about injection safety
Talk to your healthcare providers about how they are keeping you safe through careful adherence to injection safety guidelines. Pass along HONOReform’s eagerness to provider a quality educational presentation to their professional organization. Here is a useful link: HONOReform’s educational presentation program.
Today I am asking for your support for HONOReform. Your contributions enable HONOReform to educate about the absoulte necessity of injection safety to keep healthcare safe for thousands. Click this “Help Save Lives” link to reach our website to make your gift.
Thank you for your consideration. I hope to hear from you soon.
Thomas A. McKnight, MD
PS Thanks for helping with this important need. Please donate today to help with our educational efforts.
Today we share information about immunizations for children, especially viral hepatitis immunization. We are grateful to Carrington College for developing the infographic about immunizations for children.
A deadly infection of the liver, hepatitis can eventually lead to cirrhosis, liver cancer, and other dangerous conditions. Viral hepatitis Immunization is available for some types of hepatitis, but not for all.
Typically spread by close personal contact, hepatitis A does not result in chronic infection. However, its symptoms can be quite severe, so early vaccination is important. As laid out below in the child immunization guide created by Carrington College, children between 12 and 23 months old receive multiple doses of the vaccine, with doses separated by at least 6 months.
The symptoms for hepatitis B are virtually identical to those associated with hepatitis A. Unfortunately, hepatitis B can also lead to chronic suffering. According to the recommended childhood vaccination schedule, the first dose of the hepatitis B vaccine is typically administered within 24 hours of a child’s birth. Further doses will be giver over the next 18 months.
There is currently no vaccine available for hepatitis C, although researchers are working hard to change that – possibly in conjunction with an HIV/AIDS vaccine. Full prevention is not possible without a vaccine, but experts at WebMD advise that those worried about contracting the disease avoid direct exposure to blood, practice safe sex, and not share needles with others.
Prevention is important for all types of diseases, especially for infections like hepatitis that can cause years of discomfort. Children and young adults can secure adequate protection through immunization. While injection safety is a concern as hepatitis shots can spread bloodborne diseases, the recent adoption of smart syringes (with features that prevent re-use) promises to reduce the risk of vaccine-related infection.
All of us have had experience with the flu – body aches, fever, headache, fatigue, sore throat and runny nose and disruption to normal life. Having the flu can result in a personal minor annoyance or in a major health crisis. The CDC urges everyone six months old and older to receive a yearly flu vaccination. But where should you get your flu shot? There are many places to get your flu shot, ranging from your personal physician’s office to “pop-up” flu shot clinics in public places such as airports and hospitals. Make sure that that the flu shot clinic adheres to injection safety standards. Ask if the organization that is providing the flu shot has taken the pledge for vaccination clinics. Share this checklist of best practices for vaccination clinics with your flu shot providers.
When you share these resources, you may be preventing transmission of disease for yourself and others! Kudos to the Influenza Workgroup of the National Adult and Influenza Immunization Summit for developing these important resources for safety during flu shot season.
What are the next steps when your facility is ready to make a change because they are committed to patient safety? How does a facility educate their staff in the reasons for and the process of performing random drug screens on all who have access to controlled substances? What do they do when many staff threaten to quit if random drug screens are implemented? Below are some suggestions.
Excerpts taken from “Cuyuna Regional Medical Center’s Drug/Alcohol Free Workplace and Testing Policy”
Why do it (Goals):
- <Facility Name> is committed to providing high quality health care services and acknowledges the importance of each employee to the effective function of a competent health care team
- <Facility Name> sees substance abuse as a very serious problem and as a threat to employees, volunteers, patients and visitors
- The ultimate goal of this policy is to balance our respect for individual privacy with our need to maintain a safe, productive, drug/alcohol free work environment
- <Facility Name> is committed to maintaining a work environment free from the influence of alcohol and/or drugs and thereby protecting the health, safety and well-being of patients, employees, volunteers and visitors
- <Facility Name> employees are required to immediately notify their supervisor if any member of the health care team is not in appropriate mental and/or physical condition to safely perform their duties. They should not be allowed to perform any duties
- Assuming a reasonable suspicion, the employee will be escorted to the laboratory department for testing
- An individual who refuses to be tested, or whose behavior prevents completion of the testing, such as – tampering with the sample or testing materials, behavior intended to provide a dilute sample, failure to provide specimen within a reasonable amount of time (3 hours from initiation of testing) or not providing the required amount (30 cc) – will be subject to termination, other disciplinary actions, or have the employment offer revoked
- An individual has the right to refuse testing, but they must be made aware that such refusal may result in disciplinary action including termination
- For the individual’s safety, arrangements may be made for:
- Transportation: the individual will be sent home with a sober adult
- If he/she insists on driving home, city law enforcement will be notified.
- The individual will remain off work on paid leave until all drug testing results are received and confirmed
- <Facility Name> will instruct employees on the common identifying factors of drug use and diversion, some of which are:
- A nurse uses the maximum PRN dosage when other nurses use less
- A nurse insists on personal administration of injected narcotics to patients
- Statements such as…“If anybody needs help passing their pain meds today let me know.”
- A patient states that pain medication was not given but documentation shows that it has been administered
- A nurse shows frequent wastage of drugs for “spillage”
- Sloppy or poor record-keeping
- A nurse’s handwriting or charting deteriorates
- Increased absenteeism is common in end-stage addiction
- Increased disappearances from the work-site or increased taking of breaks
- Increased/frequent or long trips to the bathroom
- A nurse will often appear at work when not scheduled
- Uncharacteristic confusion, memory loss, difficulty concentrating
- Deterioration of interpersonal relationships with colleagues, staff and patients
- Will not admit errors or accepts blame for mistakes or oversights
- Personality change: mood swings, anxiety, depression, lack of impulse control
- Patient and/or staff complaints about health care provider’s attitude and behavior
Many will be angry over the facility’s decision to begin random drug screens of employees with access to controlled substances. They will cry out that it is unfair; it is an invasion of their privacy; it is costly; they may even threaten to quit and some actually will quit. Let them rant, but continue to remind them that you are committed to patient and employee safety. Your goal is to minimize, even eliminate, drug diversion at your facility and this is one of the best ways to do that.
It is important to remember that the policy is being done to maximize patient and healthcare worker safety, not to punish. The policy is not to invade anyone’s privacy. Unfortunately these days, we have to be vigilant in our quest to stop drug diversion, it is pervasive and it is getting worse. Just do a Google search for drug diversion in healthcare and you’ll see so many examples of the problems that accompany diversion. There is something we can do, we can simply drug test those with access to the drugs that are most commonly diverted. We can test the syringes that are returned as waste. We can let addicts know that we are watching them and we will discover what they are doing. Most importantly, we will get them help.
Today I would like to share a bit about the Florida Board of Nursing’s “Intervention Project for Nurses” or IPN. It is similar to other Drug Diversion Programs that many states have, but it has a piece to it that is a bit different…they have a statewide support groups for nurses. This interests me, what a great idea. To have nurses that have been through the same issues regarding drug diversion talk to those who are beginning their journey is a very valuable tool.
“The mission of IPN is to ensure public health and safety by providing an avenue for swift intervention/close monitoring and advocacy of nurses whose practice may be impaired due to the use, misuse, or abuse of alcohol or drugs, or a mental and/or physical condition. IPN is authorized by Florida Statute, Chapter 464/456, to assist those nurses whose practice is affected.”
- To ensure public health and safety through a program that provides close monitoring of nurses who are unsafe to practice, due to the use of drugs including alcohol and/or psychiatric, psychological or a physical condition (chapter 455.261).
- To provide a program for affected nurses to be rehabilitated in a therapeutic, non-punitive, and confidential process.
- To provide an opportunity for retention of nurses within the nursing profession
- To facilitate early intervention, thereby decreasing the time between the nurse’s acknowledgment of the problem and his/her entry into a recovery program.
- To require the nurse to withdraw from practice immediately, and until such time that the IPN is assured that he/she is able to safely return to the practice of nursing.
- To provide a cost effective alternative to the traditional disciplinary process.
- To develop a statewide resource network for referring nurses to appropriate services.
- To provide confidential consultations for Nurse Managers.”
The IPN has a vast network of resources for nurses. Florida has 150 Nurse Support Groups throughout the state. Each group has a facilitator. This is what one had to say, “I have been a Nurse Support Group Facilitator for over 12 years. I have witnessed many nurses come and go from my groups. The “magic” of the Nurse Support Group lies in the fact that a nurse who feels totally alone and full of negative self-talk and shame, secondary to his or her substance use disorder, attends group with other colleagues who have struggled with similar feelings and circumstances. There is a realization that “I am not alone anymore” and hope is born.” And one of the participants shared this, “Walking into my Nurse Support Group the first time surprised me. I will never forget the experience. My first surprise was how welcoming folks were to me. I listened as members shared a little about themselves with me, and I was amazed how similar the stories were to mine! I left that night with a sense of hope.”
I know when I first started this journey, I needed to speak to other people going through what I was. I was lucky in the sense that my counselor had another nurse she was treating with almost the exact same issues. What I didn’t have was someone who had been successful in going through the BON’s program and returning to practice. It would have been very helpful to have someone walk me through the process. As it was, I fumbled around with a lot of anxiety and some missteps. I would love to be a resource for nurses new to the BON monitoring program and new to sobriety. 12 step programs are essential in my opinion and they have worked so well for me, but they do not include anything about how to recover as a nurse. Including how to navigate the overwhelming program requirements, how to deal with the feelings of shame and remorse, how to get to a point where working as a nurse is a possibility again. I could be that resource, there are many like me that could. Together we can make a difference.
“Ev, you have Hepatitis C. The lab test is postive, but I have no idea how you got it.”
My husband Tom said these words to me on February 8, 2002. And thus began my life with Hepatitis C.
Months later we learned that I contracted Hepatitis C through reuse of syringes during chemotherapy. The oncology nurse drew blood from my port, put the blood in lab collection vials and then used the same syringe to access a large saline bag. That same saline bag had been contaminated with a Hepatitis C+ patient’s blood during his port flush. In all, 99 people who were engaged in the fight of their lives to overcome cancer were infected with this second deadly disease.
I’ve learned alot about Hepatitis C since then. Around the world 400 million people are infected with hepatitis B and C, more than 10 times the number of people living with HIV. An estimated 1.45 million people died of the disease in 2013 – up from less than a million in 1990.
Recently we celebrated World Hepatitis Day. It is a day to remember those who have died from the disease, support those who currently have it, and work towards prevention. The theme for this year is “Elimination.” The World Health Organization announced a strategy for dealing with the world-wide epidemic of viral hepatitis.
This new WHO strategy introduces the first-ever global targets for the elimination of Hepatitis B and Hepatitis C as public health threats. These targets include a 30% reduction in new cases of hepatitis B and hepatitis C, and a 10% reduction in mortality by 2020, and ultimately achieving even greater health impact by 2030. Key approaches to achieving these targets include:
- expanding vaccination programs for hepatitis B;
- preventing mother-to-child transmission of hepatitis B;
- improving injection, blood, and surgical safety;
- providing harm reduction services for people who inject drugs; and
- increasing access to diagnosis and treatment for hepatitis B and hepatitis C.
These are lofty goals, but so necessary.
I am one of the lucky ones. After exhausting treatment, I have no detectable virus in my bloodstream. I am profoundly grateful. I choose to live my gratitude by advocating for safe injection practices so that no one else will hear the words, “You have Hepatitis C, but we have no idea how you got it.”
Today is World Hepatitis Day and this year’s theme is “Elimination.” The World Health Organization (WHO) recently adopted the first ever Elimination Strategy for Viral Hepatitis that calls for “rigorous application of universal precautions for all invasive medical interventions and promotion of injection safety measures…”
World Hepatitis Day is a great way to raise awareness about injection safety. Here are six ways you and your organization can get involved!
1. Read and share Dr. John Ward’s blog, “Think NoHep this World Hepatitis Day.”
2. Check out CDC.gov’s World Hepatitis Day Feature.
4. Join the #NOHep Thunderclap to amplify the message on social media.
5. Pledge your support for the World Hepatitis Day campaign by sharing your organizations logo on the World Hepatitis Day webpage.
HONOREFORM’S LEARNING ACTIVITY 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