Nebraska outbreak

Not in my backyard! – When outbreaks happen again in our own hometown

Lauren Lollini and Evelyn McKnight
Lauren Lollini and Evelyn McKnight

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.

Preparing Future Healthcare Providers

" A Never Event" is being used in the curriculum of numerous healthcare training programs.
” A Never Event” is being used in the curriculum in numerous healthcare training programs.

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@HONOReform.org. Thank you!

“We’re looking for justice” – Emil’s Story

Emil Mueller's family seeks justice for him and all the victims of the Nebraska Outbreak
Emil Mueller’s family seeks justice for him and all the victims of the Nebraska Outbreak

We are so grateful to Desarae Mueller-Fichepain, whose father’s story was featured last week in the article written by reporter Matthew Hansen. And we are grateful to Mr. Hansen, who we got to know when he joined us to take a tour of one of the four factories operated here in the state by our corporate colleagues BD (Becton, Dickinson and Co.).
These exchanges, advocate to reporter and reporter to readers, are essential ones. Continued education and reeducation on proper injection safety is vital. What happened to Desarae’s dad, Mr. Emil Mueller, should not happen to anyone here in the United States—or, we think, anywhere in the world.

It is our honor to share the article, published in the Thursday, December 11, Omaha World-Herald. We thank Desarae, and all of the HONOReform advocates, for their openness, leadership and support.

Hansen: In massive hepatitis C outbreak in Fremont, the victims’ voices went unheard
Emil had fought off prostate cancer for a decade, battled it in the same steely way that he made it through each shift at Fremont’s Hormel plant. He clocked in at the plant each morning. He picked up his knife. He cleaved the fat off of giant, immovable slabs of ham.

Day after day. Year after year. No excuses. No complaining. That’s how Emil worked. That’s how he lived.

And then, in 2000 or 2001, Emil began to see the new oncologist in town, a doctor by the name of Tahir Ali Javed. He’s a nice guy, he told his daughter, Desarae.

But within months, Emil began to change. The color started to fade from his cheeks. His grit faded, too.
Read more

Have a happy, safe Thanksgiving!

Happy Thanksgiving!
Happy Thanksgiving!

Thanksgiving time is family time. We delight in family gatherings with lots of good food and great conversations. We at HONOReform wish you a wonderful Thanksgiving!

Sometimes life’s events mar even Thanksgiving, usually one of the happiest family times of the year. And when those life events are completely preventable, the disappointment is even greater.

Vicky is the daughter-in-law of one of the victims of the Nebraska Hepatitis C Outbreak of 2002. She explained the unrest that the outbreak caused in her family that Thanksgiving. Here is their story in Vicky’s words:

“Shortly after we learned that Dad tested positive for Hepatitis C, Mom called to say that they would not be coming to Thanksgiving at our house. I was shocked. Although Dad was fighting cancer, he was fairly active for an 80+ year old; he got out of the house regularly for errands and coffee with his friends. And above all, Mom and Dad loved spending time with the family, and the precious grandchildren were to be at the dinner.

When I pressed Mom for a reason, she was evasive, but finally she gave their reason: they didn’t want to risk transmitting the virus to any of the family. They were worried that by taking food off the same platters, perhaps an accidental reuse of forks or spoons would transmit the virus. Maybe even by being in the same room, the virus would be transmitted.”

Their concern was not uncommon among the community that autumn. The Nebraska Hepatitis C outbreak of 2002 was uncovered shortly before Thanksgiving. Public health officials determined that nurses at the Fremont Cancer Clinic reused syringes to access a large saline bag that was used for port flushes on many patients throughout the day. Because a patient with known Hepatitis C was treated at the clinic, the saline bag was contaminated with his blood, and therefore with Hepatitis C. Nebraska Health and Human Services notified the exposed patients, urging them to be tested for Hepatitis C, Hepatitis B and HIV. Of all the people who were tested, 99 were diagnosed with Hepatitis C, composing the largest outbreak of Hepatitis C from a single source in US history.

Because so many people in the community was affected by the outbreak, and because fear and ignorance about the disease was so rampant, it is likely that the conversation between Vicky and her in-laws was repeated in many households that Thanksgiving. Of course, viral hepatitis can ONLY be spread through blood-to-blood transmission, such as through unsafe injections. But at that time the community needed much education about this fact; the need for education about viral hepatitis continues to this day throughout the country.

Vicky went on to share:
“When I strongly assured Mom that the virus was not transmitted through the air or through saliva and that it could only be transmitted through blood, she was still reluctant. She said that even though that may be true, they didn’t want anyone to be uncomfortable by their presence. She thought it would be a jollier time for everyone else if they stayed home.

I told her no, it would not be a jolly time without you; all the family would all miss you too much. Iasked her to call her family physician and talk to him about the situation. After more argument, she finally agreed and said she would call back.

She did call back a week later and said that her family physician assured them it was safe for Dad to attend the family gathering and that they would be coming to Thanksgiving. But she was still worried for the others – worried that they would be uncomfortable with their presence. I offered to call each adult family member and assure them that they would not be at risk for contracting Hepatitis C from Dad at Thanksgiving dinner. She was very relieved by this and thanked me profusely.

We had a wonderful Thanksgiving gathering that year, perhaps made even more dear by our heightened concern and love for our dear Dad. We sat at the table a long time, reminiscing and telling family stories. It was a wonderful day, and my only regret was Mom and Dad’s worry, that nearly kept them from sharing that warm, loving family time with us.”

Vicky’s family had a lovely Thanksgiving that year, but not everyone who contracts disease through unsafe injections is so fortunate. Some will be too sick from their illness, others will let fear and worry keep them away from holiday gatherings. And all because of an illness which is completely preventable!

At your family gathering this year, do yourself and everyone else a favor. Share with your loved ones this advice from the One and Only Campaign:

In order to ensure that you are receiving safe injections, ask your healthcare providers the following questions before you receive an injection:

1.    Will there be a new needle, new syringe, and a new vial for this procedure or injection?
2.    Can you tell me how you prevent the spread of infections in your facility?
3.    What steps are you taking to keep me safe?

It Takes Courage to Speak the Truth

Lauren is the survivor of the 2009 Hepatitis C Outbreak in Colorado who chose to take a first step to passing legislation to make patients safer.
Lauren is the survivor of the 2009 Hepatitis C Outbreak in Colorado who chose to take a first step to passing legislation to make patients safer.

As a therapist, I often find myself congratulating clients for taking the first step as that is usually the most difficult. That first step might be making a phone call and asking about what resources are available for help or quite literally taking that first step into my office. So, too, do I congratulate the past contributors to our blog who have gone above and beyond to take that first step to share their stories. By speaking their truth, they have risked much, but were still undeterred.

You simply need to scroll back through the last few months and you will find many heroes who could no longer stay silent. Most recently, Anita Betrand shared her journey from addiction as a CRNA to that of an advocate speaking out so others can learn from her. Her struggle in and of itself was an arduous one, yet Anita chose to take that one next step to help educate so other healthcare workers finding themselves in a similar circumstance know there is a light at the end of the tunnel.
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

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

The many “Love Stories” that have been altered by unsafe injection practices

Evelyn & Tom McKnight are survivors of the Nebraska Outbreak
Evelyn & Tom McKnight are survivors of the Nebraska Outbreak

On behalf of my wife Evelyn and everyone who helps sustain the efforts of HONOReform, thank you very much for your support. In the letter I sent in November, I ask the wonderful people we have met and worked alongside through the years to provide a donation to HONOReform. This request is getting a good response. I thank you all.

And, naturally, I encourage everyone to please think of HONOReform here at the end of the year…and throughout 2014 and beyond. We depend on your kindness and generosity. Every donation is meaningful. You are helping us continue to help safeguard the medical injection process in the United States. If you haven’t already, will you please consider a gift to HONOReform?

In a blog post scheduled for early next year, our executive director, Steve Langan, will share some of our highlights of 2013—and some of our goals for 2014. We encourage you to join us!

In my appeal letter we mailed in November, I shared part of my story, our story—what can happen when a loved one is affected by unsafe injection practices. Even one unsafe injection can devastate a person and his or her family. Every part of the injection safety process “from manufacting through disposal” (as Evelyn says) must be done correctly.

I talk about the many “love stories” that have been altered by unsafe injection practices. I have been there. Many others have been there, too. Let’s continue to work to prevent outbreaks and infections caused by unsafe injection practices.

I would like to switch gears for a minute, and talk to you about injection safety from the point of view of health care providers. As many of you know, I have been a family physician for many years. It is not a stretch to say, at this point in my career, “I’ve seen it all.”

I call on my colleagues—not just physicians but nurses and every member of the staff in a clinic or hospital—to always provide a safe injection, each and every time. This continues to be my goal. A call to action to everyone who gives an injection…to make sure it’s being done correctly.

That said, it is now more important than ever that we communicate. There is so much technology in play in hospitals and clinics—from electronic medical records to apps of all kinds—that I think we providers sometimes forget to take some time to talk with one another.

My wish for 2014 is that we emphasize communication here in Fremont at our clinic. And that we are never shy or hesitant about addressing a situation in which any aspect of health care is questionable. As they say in the airports, If you see something, say something. This especially applies to any potential violation of the injection safety. Lives depend on it.

I extend this important call to action to my fellow providers, here in Nebraska and throughout the country.

 

“I know I have to forgive” – the Brader family story

Amanda and Mary Brader
Amanda and Mary Brader

Dwight and Mary Brader had a storybook life. They had a loving marriage, a young daughter who was the apple of their eye, and they lived on a farm in Nebraska. Mary worked nights as a nurse at a hospital thirty minutes away and Dwight had just finished training as an electrician in addition to keeping up with the farm chores.

And then their lives took a sudden, sharp turn. Dwight was diagnosed with nonHodgkins lymphoma. The local oncologist was optimistic that Dwight would be cured, even though his tumor was the size of a grapefruit.

Read more

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