healthcare safety

National Patient Safety Week

PfP Boxed logo-1

I am honored to be a patient advocate with the Patient and Family Engagement Network of the Partnership for Patients. The Partnership for Patients initiative is a public-private partnership working to improve the quality, safety and affordability of health care for all Americans, and I am very proud of its efforts to achieve its goal of 40% reduction in hospital acquired conditions and a 20% reduction in hospital readmissions compared to 2010.

As patient advocates, our role with the Partnership is to encourage and support collaboration between healthcare providers and patients and families to improve healthcare and reduce cost. Along with other advocates, I posted to the National Patient Safety Foundation’s website blog to highlight Patient Safety Awareness Week 2014. In the words of fellow advocate Helen Haskell, ” Patient Safety Awareness Week has been an important symbol of hospital involvement in patient safety. It is not just about safety, but about awareness of all that patients can teach health care providers about themselves.”

Following is my blog celebrating the patient/provider partnership. Read more

Where Infection Control meets Drug Diversion

Our guest blogger this week is Chuck Griffis, CRNA. Chuck is a certified registered nurse anesthetist and travels the country lecturing on infection control and safe injection practices for the AANA Practice Committee. We thank him for joining his efforts with AANA and HONOReform in working to stop drug diversion and prevent patient infection.

Chuck Griffis, CRNA
Chuck Griffis, CRNA

I work in the OR as a clinical nurse anesthetist 2-4 times a month in addition to serving on my state and national nurse anesthetist organizations, and conducting research in chronic pain. One of my roles is to serve as infection control liaison to the Practice Committee of the AANA—so I understand infection control and clinical setting challenges.

Infection control meets drug diversion in one particular setting: where anesthesia providers have drawn up controlled substances with which to sedate patients. Folks who don’t do clinical work will often ask—how could these drugs and sterile syringes wind up being stolen or swapped for contaminated devices containing saline? Aren’t all providers supposed to keep all controlled substances under immediate visual and personal control at all times? How could this happen? Allow me to explain how the real clinical world works. Read more

Una Jeringa, Una Sola Vez, part 2

As promised, here is a video of Guatemalan healthcare providers talking about the importance of injection safety. We thank them for their dedication to the safety of their patients!

Trinis: It is important to use only one time one needle and one syringe!

Mary: Using one needle and one syringe only one time, we are preventing the transmission of disease.

Pedro: As healthcare workers, we have the obligation to teach others about this information, not only to other healthcare workers, but also to our patients.

New Hampshire Legislature Efforts to Provide Patient Safety by Tom Sherman, MD

Over the past two and half weeks, the New Hampshire legislature has passed two new bills to address drug diversion.

The history of these bills began in the spring of 2012 when my partner and I noted that we had two patients with acute hepatitis C under our care. Neither of us had seen acute hepatitis C in our practices since it usually presents as a chronic disease. The common thread was our cardiac catheterization lab. We reported these immediately which began the cascade of events eventually resulting in identification of 10,000 patients at risk nationwide from 17 hospitals. At our hospital, there were 32 cases that resulted from drug diversion by a medical technician named David Kwiatkowski.

I have had the dual advantage of being a member of the state wide Drug Diversion Task Force, a working group that arose following this episode, as well as being elected to the New Hampshire State Legislature House of Representatives in the same year. Two pieces of legislation had been introduced to address the problem of drug diversion as a response to this incident. I took these pieces of legislation, with full support from their sponsor, to the Task Force. With all of the major stakeholders participating and with the hard work of legislative subcommittees, we were able to revise these two pieces of legislation to address the problems identified by our Department of Health and Human Services as a result of its investigation of the outbreak.
Read more

Una Jeringa, Una Sola Vez

Tom and Evelyn McKnight gave a presentation on injection safety to Guatemalan healthcare workers
Tom and Evelyn McKnight gave a presentation on injection safety to Guatemalan healthcare workers

Tom and I were privileged to participate in a mission trip to Guatemala, led by Guatemala Esperanza’s Ron Noecker, a former HONOReform board member.

Our team co-operated with several other organizations to provide health screenings, build a health clinic and provide healthcare provider education.

Guatemala is a lovely country, very lush with beautiful cities, lakes, volcanoes and villages. It also has many challenges. Read more

A giant step forward by Lauren Lollini

It has been almost five years since many of my fellow Coloradoans and I were wondering if we would be okay, if we would live. I had learned of my hepatitis C diagnosis months earlier than the others, as I was symptomatic, most of the victims were not. I kept asking how this could happen to me, all the while fearing that it wasn’t just me suffering. I feared for my future. I feared for the future of my daughter, Lucy, who was just one year old. A few months later, in July 2009, we learned that Kristen Parker, one of three known drug diverters in recent years to infect patients, had been the source of this deadly disease. Thousands of letters went out to patients who may have come into contact with Kristen and therefore put into harms way.

Unbeknownst to me at the time, I was following in the very brave footsteps of Evelyn McKnight and HONOReform. So with the support of some vital people, I tried to make a difference. I could not stay silent. I spoke to media and told my story and the story of the outbreak. I tried to put a name and a face to this tragedy, as some of the victims were too ill to speak out for themselves. Soon some Colorado lawmakers approached me to work with them to help make some real changes. And we did! I am proud of the two bills that were passed in 2010 HB 1414, concerning the reporting Identity in Injectable Drug Diversion (Benefield/Foster) and
HB 1415, Sunrise Surgical Tech Registration (Gagliardi/Morse)
Read more

Seeing for ourselves how safety is engineered into medical injections

BD hosted HONOReform and reporter Matthew Hanson for a plant tour
BD hosted HONOReform and reporter Matthew Hansen for a plant tour

What a great way to end the week!

Steve Langan and Matthew Hansen, features writer for the Omaha World-Herald, picked me up at my house on Friday morning, and we drove to a meeting at the BD (Becton, Dickinson and Co.) plant in Columbus. It’s one of two BD plants in Columbus. There are two others in the state, one in Broken Bow and another in Holdrege.

Congressman Jeff Fortenberry, a longtime supporter of injection safety whose district now also includes the Columbus area, was at the meeting. He met with our BD colleagues and the HONOReform team, and then he led a town hall meeting for BD employees.

I value Congressman Fortenberry’s straightforward, genuine approach to governing. Read more

A New Infographic to guide Healthcare Workers

Evelyn and Tom McKnight had the privilege of presenting to the Central Illinois Chapter of the Association of Professionals in Infection Control last week. Here four infection preventionists discuss the new infographic that gives guidance on the single dose/multidose vial issue. See the infographic at

“I’ll be clicking my high heels all over the world about injection safety”

Kim James is an employee health nurse at Brookdale Hospital in Brooklyn and member of the New York One & Only Campaign workgroup. Here she talks about her passion for injection safety.

Hello everyone my name is Kim James and I am a nurse practitioner in charge of occupational health at Brookdale hospital. As a nurse practitioner one of my concerns is injection safety, especially among healthcare workers. In doing research for our Informative Day for workers in injection safety, I ran across the CDC’s One and Only Campaign.

In that Campaign I found out and was horrified by the fact that so many consumers have contracted HIV, Hepatitis B and Hepatitis C from healthcare providers. That knowledge so moved me that I have decided to really take action and to do my part to help spread the word and to see if I can in any way contribute to stemming this absolutely unfortunate practice.

I have a saying that I will be “clicking my high heels all over the world” as I try to get this message out.

I like to travel and one of the things I like doing is a little bit of community service when I go to visit. So I plan to share this knowledge every place I go. If anyone will listen to me even for a minute, I‘m going to do the very best I can with my last breath to stem unsafe injection practices that are harming our patients.

One IV Bag, One IV Tubing and Only One Time

Evelyn McKnight is a survivor of the Nebraska outbreak, in which 99 cancer patients contracted Hepatitis C through reuse of an IV bag on multiple patients.

One IV Bag, One IV Tubing, and Only One Time
One IV Bag, One IV Tubing, and Only One Time

Recently, I had what started out as a minor health situation. But as time went on, I experienced a cascade of health complications which resulted in a not-so-minor situation. I neared dehydration, and I would need IV fluids if my condition continued to  deteriorate. The thought of an IV infusion panicked me, and I asked for 24 hours before we began IV fluids.

As I chugged Gatorade, I tried not to think about the last time I had an IV infusion, which was during chemotherapy in 2000. The nurse reused syringes to access a mutidose saline bag. When a nurse used a syringe on a patient with known Hepatitis C and then reused the same syringe to access the IV bag,  the IV bag was contaminated. This happened multiple times during the day; in fact, it was found during an investigation by Nebraska Health and Human Services that after a day’s use, the bag was cloudy, pink, with bits of sediment. In this way, 99 Nebraskans contracted Hepatitis C. Read more

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