Survivor Stories Blog
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.
I was honored recently to speak to the RN to BSN nursing class of the College of St Mary in Omaha, NE. It was heartwarming to interact with such eager and engaged nursing students – their passion for quality nursing care is contagious! The discussion was lively and revealed the students’ quest to understand how they can assure that their care of patients will always be safe.
It was particularly timely to visit the class because this week is National Patient Safety Week and the launch of the healthcare provider pledge for injection safety. Healthcare providers throughout the country will be pledging:
We urge you to take the pledge as well. If you are a healthcare provider, have some fun with taking a selfie with your signed pledge and posting it to your social media channels. Get a group shot with your colleagues. If you are a patient, ask your healthcare provider to sign and take a picture of yourself with her holding the pledge. Here are several pictures of some of my favorite healthcare providers with their signed pledges:
Will you sign this pledge?
“I will use a new needle. I will use a new syringe for you. This is the one and only time they will be used.”
Several new investigations into healthcare associated transmission of bloodborne pathogens have been reported lately. Lauren recently reflected on an investigation into possible drug diversion by a surgical tech that could result in transmission of hepatitis C from the surgical tech to patients through reuse of syringes in the Denver area. A recent news article reported on a situation in which a nurse employed by an Omaha wellness company reused two syringes to administer 67 flu shots.
Of course we are horrified by these potential outbreaks, as we always are whenever there are reports of unsafe injection practices. Our hearts go out to those affected by the unsafe practices. We know the anxiety, anger and betrayal that many feel, because we have felt those same feelings ourselves when we contracted Hepatitis C through reuse of syringes and medication vials.
But what makes these reports of potential outbreaks even more difficult for us, is that they are linked to our own backyards.
Lauren lived in the Denver area for many years, and was affected by the Rose Medical Center outbreak through drug diversion in 2009. Evelyn lives in Fremont, NE forty miles from Omaha, and was one of 99 people who contracted Hepatitis C through reuse of syringes during chemotherapy in 2002.
Ever since we were harmed by unsafe injection practices, we have worked hard to educate about and advocate for injection safety. We have wept with victims, argued with policy makers, and encouraged healthcare providers, educators and administrators to do the right thing for many years now. The work is consuming, demanding, – but usually rewarding.
But when the outbreaks happen in our own backyard, we feel so many more emotions. Anger. Frustration. Discouragement.
Perhaps the most salient emotion is bewilderment. How can this be? Didn’t everyone read about our outbreak in the newspaper, or see a report on TV? Wasn’t everyone shocked and horrified? Didn’t we hear over and over again – “We can’t let this happen again!”
And yet it did. Of course changes were made – even sweeping changes – right after our outbreaks. We were gratified by the improvements that we saw implemented. But time moves on – people change jobs, memories dim, attention to safety is threatened by the demanding pace, or cost cutting, or a culture of poor communication within the healthcare team. And then reuse of medical equipment intended for one time use happens again, either intentionally or unintentionally.
And then we are back to where we were years ago – weeping with victims, arguing with policy makers, encouraging healthcare providers, educators and administrators – in some instances the very same officials we interacted with at the time of our outbreak.
At times like these we have to sit back, take a deep breath, and reflect on our advocacy. Are our efforts worthwhile? Should we continue? And almost immediately, the answer comes from deep within – “YES!”
For although we learn through the media for months about the number of people who were affected by unsafe injections in our hometowns, we do not know how many people we have saved from injury through our efforts. We know it is a great many. We know that the educational efforts of the One and Only Campaign and the advocacy efforts of the Drug Diversion Prevention Committee are making a difference. We know this whenever someone comes up to us after hearing us speak and tells us, “I’m taking your story back to my co-workers, and we are going to make some changes!” We carry those statements in our hearts, and bring them to the top of our minds at times like these.
So. Back to work. Lets all commit to making “One needle, one syringe, and only one time” happen everywhere in the world, not just in our own backyards.
News broke a few weeks ago about a possible drug diversion event in Colorado. The more we here about the details of this incident, the more we understand just why a national registry for healthcare workers is so important. Even with the current registry the state of Colorado has for surgical technologists, we see that we have still fallen short in regard to gaps in the system.
It appears the surgical tech who was caught with a syringe in an operating room where he was not scheduled has lost every previous hospital job due to drug violations. At least one other job he was caught stealing a syringe and in still another he tested positive for fetanyl. It appears 4 states are now involved in an ongoing investigation. Read more
I was fortunate to be part of a group of committed advocates who met with their congressional delegation to advocate for safe patient care. Join us in our efforts as we share our story here in a two minute video.
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.
Nine years ago, HONOReform was launched. We pause here to review our many accomplishments. We give thanks to our loyal stakeholders and supporters, who have made all of this possible!
- HONOReform is an original member of the Safe Injection Practices Coalition, which is currently active in seven states and online at OneandOnlyCampaign.org. This award-winning campaign is led by our longtime partners at the CDC.
HONOReform is proud to reprint board member Pam Demski-Hart’s recent contribution to the CDC’s Safe Healthcare blog. Pam is the principal and founder of Healthcare Accreditation Resources LLC, a consulting service for ambulatory healthcare and dental facilities. Following is part two of a blog series recounting her personal observations of unsafe injection practices in healthcare settings. Pamela asks, “How do we get every healthcare worker on the same page when it comes to infection control practices?”
In my last blog post, I discussed the differences between reality and perception when it comes to what safe injection/infection control practices are — and are not.
So, how do we get every healthcare worker on the same page when it comes to reinforcing correct procedures? Especially when some healthcare workers are in a sort of denial that unsafe practices actually do happen. Or, worse yet, when they are absolutely convinced they are doing the right thing when, in fact, they couldn’t be more wrong. Read more
HONOReform is proud to reprint board member Pam Demski-Hart’s recent contribution to the CDC’s Safe Healthcare Blog. Pam is the principal and founder of Healthcare Accreditation Resources LLC, a consulting service for ambulatory healthcare and dental facilities. She shares in this blog her personal observations of unsafe injection practices in healthcare settings. Pam discusses the differences between reality and perception when it comes to what infection control practices are — and are not. The blog is posted here in its entirety. We urge you to share with all healthcare providers, and to combat the dangerous denial of the presence of unsafe injections.
They greet me at the facility door with a handshake and a cheerful comment, “We’re pretty sure we’re OK!”
And that’s when I cringe and prepare myself. Read more
At this time of year, we review our activities of the previous year. Join us as we look back on 2015 through the lens of HONOReform.
OUR MISSION AND VISION
HONOReform is the only national advocacy organization dedicated to protecting patients by safeguarding the medical injection process “from manufacturing to disposal.” Our vision is a nation in which healthcare providers always follow fundamental injection safety practices that protect patients with every injection.
Evelyn McKnight shared her story and the ongoing efforts of HONOReform at the landmark World Health Organization Safe Injection Gliobal Network meeting. At the end of the meeting, WHO representatitves shared the goal of having single-use only injection devices in use in developing countries by 2020. Additionally, Steve Langan represented HONOReform in Glasgow, Scotland at the first international meeting hosted by the World Hepatitis Alliance.
PRESENTATIONS AND MEDIA
Led by co-founder and president Evelyn McKnight, who frequently presents her story and the ongoing need to always use safe healthcare practices, HONOReform presented at 30 events in 2015 attended by over 2500 people. HONOReform was featured in local and national media dozens of times in 2015, including an appearance in the May 21 US News and World Report article, “Unsafe Injections Put Patients in Peril.”
Evelyn and HONOReform are active on social media, particularly twitter (#HONOReform). On our streamlined website, click on “JOIN THE CONVERSATION” to receive up-to-the-minute information from HONOReform (on Twitter and Facebook). Also, be sure to check out and subscribe to the HONOReform blog, “Survivor Stories,” edited by Evelyn and Lauren Lollini. To submit an idea for our blog or an article, contact Steve Langan at 402.659.6343 or steve@HONOReform.org.
OUR ACADEMIC PARTNERS
HONOReform appreciates the many opportunities this year to meet, in person and online, with students from numerous universities and colleges, as they studied the consequences of unsafe injections. We welcome the opportunity to share the HONOReform story and highlight the need to always emphasize injection safety. Our academic partners include University of Nebraska-Omaha, Midland University, Methodist Nursing College, the College of St Mary, St Louis Univerity and Southeast Community College – among others.
THE SIPC AND THE CAMPAIGN
HONOReform is a proud member of the Safe Injection Practices Coalition (SIPC), which provides support for the One and Only Campaign. The SIPC continues to develop and distribute its award-winning materials, and we continue to raise awareness among healthcare providers and patients about the absolute need for safe injection practices. As always, please contact HONOReform and allow us to help you access the matierals that will be most useful to you and your institution-if you are a healthcare worker-or your family-if you are a patient.
Sadly, some healthcare providers in the United States continue to reuse and misuse medical equipment, including syringes. Additional focus areas this year included reuse and misuse of single- and multi-dose vials of medication and responding to increasing reports of drug diversion among healthcare workers. Through the HONOResponse program, HONOReform is poised to help patients and communitities immediately following a patient notification or confirmed outbreak.
SOME GOALS FOR 2016
Thank you to our supporters for helping us work toward these goals:
To develop an education program, at no or reduced cost, on injection safety for healthcare workers and to work in tandem with colleagues to advance these and other infection prevention efforts.
To organize and help host a national meeting on drug diversion prevention and then to follow up on the action steps we adopt at the meeting to influence mitigation and elimination of the problem.
To continue to encourage international leaders to focus on making injection safety a priority.