One and Only Campaign

A Survivor reacts to a new outbreak

Johnny and Janet Robertson
Johnny and Janet Robertson

Recently West Virginia health authorities announced that a cardiac clinic is at the center of an investigation of a potential outbreak of viral hepatitis through unsafe injection practices. Johnny Robertson of North Carolina is a survivor of a similar outbreak and is an active advocate of injection safety. We are grateful to Johnny for his leadership in patient advocacy. Following is his reaction to the outbreak.

In January 2008, I heard the words, “You have hepatitis C.” This diagnosis changed my life completely.

I contracted hepatitis C during a stress test at a cardiology clinic in North Carolina in 2007. Later, it was revealed that a medical technician administered saline solution to a patient who was infected with this life threatening disease, then reused the same syringe to re-enter the vial. This contaminated the vial of medication with the virus. Subsequent patients who received an injection from the saline solution vial were exposed to the virus. Five patients were infected with the virus, but many more were exposed and were urged by the state health department to be tested.

Several weeks ago, West Virginia’s Department of Health and Human Resources sent letters to 2,300 people potentially exposed to hepatitis B, hepatitis C and HIV through cardiac stress tests at Raleigh Heart Clinic in Beckley. From the recent article (“Hepatitis cases linked to Beckley clinic likely caused by human error,” March 29), we know that 12 patients have been infected with hepatitis C or hepatitis B.

This tragic news strikes an eerily similar tone.

In addition to the dozen patients who have been infected, my heart breaks for the patients who sit and wait and worry while results from blood tests come back. I offer them my deepest support.

Outbreaks like this one oftentimes affect entire communities. Families and friends and colleagues are affected. They take a toll on the human psyche, and they are complicated and costly.

The truth of the matter is this could have been prevented. It did not need to happen.

Generally, healthcare in the United States is very safe. But sometimes, unsafe practices are used—brought about by ignorance, desire to cut costs, or the demand to see more patients in a shorter amount of time.

But there are efforts to educate both healthcare providers and consumers about the absolute need for safe injections in all settings.

I work alongside colleagues at Hepatitis Outbreaks’ National Organization for Reform and North Carolina’s One & Only Campaign. I am proud to serve as a spokesman for this award-winning campaign. I tell my story to healthcare providers throughout the state to help reeducate and advocate for injection safety, urging them to use “One needle, one syringe, and only one time!”

Patients need to have a voice in healthcare. No one in the United States should be infected with hepatitis C while receiving healthcare. My hope is to support those who are going through this very difficult time and allow the conversation to begin about tighter safety protocols, in West Virginia and elsewhere. There is help out there for those who need it. I know because I was once in this same situation.

Johnny Robertson

Drug Diversion Management; A Resource Guide

Lauren Lollini is a patient safety advocate who has been integral in changing laws to keep patients safe as well as a member of the Drug Diversion Prevention Committee.
Lauren Lollini is a patient safety advocate who has been integral in changing laws to keep patients safe as well as a member of the Drug Diversion Prevention Committee.

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.
Read more

Take the pledge for Patient Safety Week!

The RN to BSN students of College of St Mary's take the pledge for injection Safety
The RN to BSN students of College of St Mary take the pledge for injection Safety

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:


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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:

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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.”

Another plea for a national healthcare registry

Lauren Lollini is a patient safety advocate who has been integral in changing laws to keep patients safe as well as a member of the Drug Diversion Prevention Committee.
Lauren Lollini is a patient safety advocate who has been integral in changing laws to keep patients safe as well as a member of the Drug Diversion Prevention Committee.

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

Another Drug Diversion Event in Colorado

Lauren Lollini is a patient safety advocate who has been integral in changing laws to keep patients safe as well as a member of the Drug Diversion Prevention Committee.
Lauren Lollini is a patient safety advocate who has been integral in changing laws to keep patients safe as well as a member of the Drug Diversion Prevention Committee.

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.

Swedish Medical Center infection scare didn’t have to happen – The Denver Post

Celebrating our Successes

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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.

Read more

HONOReform’s Annual Report

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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.

HONOREFORM INTERNATIONAL                                                                                    
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.”

HONOREFORM OUTREACH                                                                                              
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.

HONORESPONSE                                                                                                                      
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.

 

Reused syringes causes infection control breach in New Jersey

Lauren Lollini is a patient safety advocate who has been integral in changing laws to keep patients safe as well as a member of the Drug Diversion Prevention Committee.
Lauren Lollini is a patient safety advocate who has been integral in changing laws to keep patients safe as well as a member of the Drug Diversion Prevention Committee.

Last week, reports of a nurse administering flu shots to 67 employees in New Jersey was found to be reusing syringes. While the risk for transmission appears to be low in this incident, it is yet another reminder about how easy the episode of exposure for an infectious disease can be. One shortcut taken either to save time or money can put patients at risk for HIV, Hepatitis B or C.

More than 150,000 patients have been told, over the last 10 years, they needed to get tested following a syringe misuse to include syringe reuse. Despite the protocols put into effect by the CDC, we continue to hear stories of patients put into harm’s way.
Read more

Possible Hepatitis, HIV Exposures in Santa Barbara, CA

Lauren Lollini is a patient safety advocate who has been integral in changing laws to keep patients safe as well as a member of the Drug Diversion Prevention Committee.
Lauren Lollini is a patient safety advocate who has been integral in changing laws to keep patients safe as well as a member of the Drug Diversion Prevention Committee.

My heart skipped a few beats last week when I read about the potential outbreak resulting from a lack of safe infection control measures in a doctor’s office in Santa Barbara County. Things had been going fairly smoothly in regard to safe injection practices. In 2014, none of the investigations which took place found any disease transmissions. In fact, we had not had an investigation over the last six months and although we never stop educating and spreading awareness, we were able to breathe a small sigh of relief. Read more

Injection Safety is a Global Priority

The Safe Injection Global Network is launching a new campaign
The Safe Injection Global Network (SIGN) is launching a new campaign

Steve Langan and Evelyn McKnight recently attended meetings of the Safe Injection Global Network, sponsored by the World Health Organization, in Geneva, Switzerland. Following is their report.

How thrilling to be part of a global effort to advance injection safety! It was a rewarding moment when we entered the doors of the World Health Organization in Geneva, Switzerland last month to participate in meetings of the Safe Injection Global Network.

We joined dedicated advocates of many countries, all working to eradicate reuse of syringes and needles, misuse of medication vials and unnecessary injections. Although we differed in language, culture and homeland, we were united in our passion to prevent disease transmission through unsafe injections everywhere – from India to Egypt, Uganda to the United States, and everywhere in between.

Representatives from Nepal, Brazil, Pakistan and the United Kingdom said to us, “We’ve seen and admired the website of the One and Only Campaign. We’d like something like it in our country.” We were proud to share some highlights of the One and Only Campaign with the assembly, and we are eager to work with SIGN to bring it to all countries.

Here is a 2 minute video that shares some of the highlights of the new SIGN Campaign. We will share here further developments as the campaign unfolds!

© Copyright 2016 HONOReform