As we commemorate World Hepatitis Day, we remember that unsafe infections transmit infections. We are grateful to the World Health Organization for its efforts in preventing viral hepatitis globally. Many cases of viral hepatitis are transmitted by unsafe injections. Following is a poster to guide healthcare providers in administering safe injections.
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.
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.
Prior to my 2009 Hep C infection I paid little, if any, attention to issues of safe injection practices, drug diversion or outbreaks. In my ordinary life, I had no concern for such things. In fact, I am not even sure I could adequately define any of those terms prior to the chaos of 2009 and the outbreak in Colorado.
But since, I have kept myself in the know, paying attention to trends, outbreaks and legislation to protect patients. My email inbox and social media accounts are littered with stories, mostly bad, about errors in patient care. I truly hope that some of the initiatives I have become a part of will put a stop to most of these incidents. However, in preparing for every situation in an attempt to prevent these events you will find a tale so far fetched you want to read the facts 2 or 3 times just to insure what you initially thought you heard was correct. Read more
Earlier this year, I commented on the closure of a medical office in Santa Barbara for various infection control violations. It was in the first half of the year and I was feeling hopeful because in 2014 none of the investigations which took place were found to have any infectious disease transmissions. And then in early April news spread the office of Dr. Allen Thomashefsky’s was being investigated.
I felt it important to report again on this situation almost 6 months later as the office was given the approval to re-open last month. Am I disappointed that his practice was able to stay open in Oregon with certain restrictions in place? Am I saddened that this California office was able to be re-opened? Not as long as the proper procedures are implemented. Read more
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
Starting in July 2009, when we read reports of the outbreak at Rose Medical Center in Denver, HONOReform became involved in drug diversion prevention. An addicted healthcare worker diverted medication for her own use, refilled syringes with saline and then left them to be administered to patients. Diversion of narcotics is a patient safety issue and it’s an injection safety issue…and so much more.
One of our aims is to encourage colleagues throughout the country to address drug diversion at a national and federal level. We are grateful for the positive response we are receiving. We will provide an update with more specific information in the near future.
Drug diversion is not an uncomplicated problem. It is the space where bureaucracies, including healthcare systems and law enforcement, come together. Oftentimes, a thorough awareness of the problem is lacking—and the necessary and proper procedures are not in place.
We are glad to share this 17-minute podcast, a clear description of the problem and some of the solutions, on our blog this week. Kimberly New, JD RN, of Diversion Specialists, who is one of the leading voices of drug diversion prevention and a close colleague of HONOReform, talks with Dr. Howard Zucker, MD JD, Commissioner of the New York State Department of Health.
In this interview, Kim New says, “We need to identify problems quickly and protect patients from potential harm.” We could not agree more. Thank you, Kim and Dr. Zucker, for coming together to address the problem, and thanks to our colleagues at the New York Health Department for encouraging and organizing this conversation.
The lengthy article was written by Kurt Eichenwald and was the result of an interview and correspondence with David Kwiatkowski, the radiologic technician who was sentenced to 39 years in prison after infecting patients with hepatitis C through unsafe injection practices. Kwiatkowski, who was infected with hepatitis C, stole injectable pain medications from the hospital where he was working and injected himself. He changed the needle, rinsed the syringe with water, refilled the syringe with saline and put these syringes back on the medication cart for use with patients. In this way, at least 45 patients in seven states were infected with hepatitis C. One patient has died from the infection.
Regrettably, this scenario is not unusual in the United States. The CDC estimates that 30,000 people may have been exposed to hepatitis C over the past decade by infected hospital employees who have used narcotics intended for patients. Federal researchers estimate that 100,000 healthcare workers in the United States are addicts and their theft of narcotics from patients is believed to be widespread. As many as 379,000 health care workers in the United States are addicted to drugs or alcohol, according to New Jersey pharmacist Mitch Sobel, who delivered this information at a recent New Jersey Department of Health meeting.
Getting back to the excellent Eichenwald article, what is unusual is that Kwiatkowski apologized…and desribed how he diverted drugs so that we can correct the healthcare delivery system to prevent harm to the public.
Since he is not eligible for parole, Kwiatkowski has nothing to gain from his disclosures. In fact, he and prison officials fear the article might anger other inmates and place him in danger.
As one who contracted hepatitis C through unsafe injection practices, i want to commend Mr Kwiatkowski for apologizing and sharing his story. It is so meaningful to victims when there is an apology; I still yearn for the gift of this simple, but profound gesture of respect. It is very difficult to fully heal from harm of this magnitude without an apology–it is as if something is missing, and closure is impossible.
Kwiatkowski not only apologized, but gave us a clear picture of how diversion takes place in hospitals. This important “insider” knowledge–not unlike when casinos ask cheaters to help them catch other cheaters–will help us make the changes that are long overdue. As we reported in a previous blog, HONOReform is helping to head efforts at a national level to help prevent drug diversion. We encourage all stakeholders to join us.
In the Newsweek article, Kwiatkoski said he is “haunted by the knowledge that he hurt so many people and believes he needs to make amends by revealing the scope and methods of this medical crime that endangers un unknowing public. “
Somebody has to tell how it’s done, how easy it is and how the structure of the hospitals isn’t any good to stop it,’ he says of drug diversion.”
Examining all ways to prevent drug diversion has never been more important. Patients throughout the country are harmed, and there is no national system in place to stop diverters. From just one patient affected by unsafe injection practices, thank you, David Kwiatkowski, for your candor. We need you and others continue to tell us how to fix the system that is so easy to violate.
May is National Hepatitis Awareness month and this year the CDC is designating May 19th as National Hepatitis testing day. This is an excellent reminder for the healthcare community and others to get tested.
Not me, you say? Let me tell you why ignoring this might be a deadly mistake. According to the CDC over 4 million people in the US have chronic hepatitis C and most have no idea. Many of our baby boomers are infected and because they show no symptoms, they are clueless to the infection and the damage it is doing to their bodies. http://www.cdc.gov/hepatitis/TestingDay/index.htm Read more