Evelyn McKnight

Announcing a new injection safety continuing education program

HONOReform

HONOREFORM’S LEARNING ACTIVITY PROGRAM

The Healthcare Learning Activitity Grant Program provides a quality continuing education presentation at low or no cost. HONOReform will provide a grant to organizations sponsoring

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continuing education activities for healthcare professionals or consumer-focused activities.

Attendees will receive a flash drive containing the PowerPoint presentation, resources for injection safety, and the award-winning book: A Never Event: Exposing the Largest OUtbreak of Hepatitis C in American Healthcare History.

Description of Offered Programs
Healthcare providers in all types of settings have reviewed and followed safe injection best practices. Nonetheless, the “unthinkable” still happens, with significant impact on the patient and providers. The CDC estimates that there have been more than 50 outbreaks of Hepatitis C and/or Hepatitis B in the past decade due to reused needles, syringes or medication vials. Evelyn and Tom McKnight, founders of HONOReform, will share their own compelling story of infection attributed to reuse of syringes in a medical setting. Additionally, the McKnights will examine factors contributing to the outbreak and make recommendations for prevention.

1. “A Never Event – Don’t let it Happen in your Facility!”
A survivor describes a Nebraska “Never Event” in which 99 patients contracted Hepatitis C when a nurse reused syringes during chemotherapy administration. Root causes of the outbreak are examined as well as resources for prevention.

2. “Preventing Healthcare Transmission of Disease through injection Safety”
This presentation examines causes of patient-to-patient, patient-to-provider and provider-to-patient transmission of disease and offers resources for prevention.

3. “Injection Safety in Dental Practice”
Since 2012 thousands of patients have been put at significant risk of acquiring infectious disease from dental practices in four states. In one instance, the Colorado Department of Health notified 8000 patients that they were at risk for contracting Hepatitis B, Hepatitis C and HIV because their dentist’s practice reused needles and syringes. The McKnights will examine factors contributing to the outbreak and make recommendations for prevention in dental offices.

4. “Becoming an Empowered Patient”
Patients are learning that to receive the best quality healthcare, they need to effectively partner with their healthcare provider. A physician and a survivor of medical error discuss their own personal experiences of patient empowerment and ways to improve the physician-patient partnership.

For more information and to apply, go to Learning Activitiy Program

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It is my honor to highly recommend Dr. Evelyn V. McKnight as a speaker. I can think of no one better to present this information. Without a doubt, she exemplifies the motivation and goal-directed approach, in concert with the knowledge and passion to deliver this complex issue. Wanda O. Wilson, PHD MSN, CRNA, Executive Director, American Association of Nurse Anesthetists

Evelyn tells her story with compassion and purpose with the intention to educate listeners about the egregious unsafe practices that continue unabated in healthcare practice sites. I enthusiastically recommend Evelyn McKnight to any group seeking to educate and inspire its members! Janice M. O’Dowd, Certified Continuing Medical Education Professional, Kent Hospital, Warwick, Rhode Island

The McKnights put together an extensive slide show presentation, with multiple resources for further education. They provided tools for healthcare providers to use in their jobs to help educate other providers and present healthcare associated infections. … If you are looking for an engaging educational presentation for your next healthcare conference, I would recommend Tom and Evelyn McKnight. They were very well received, and did a wonderful job. Michele Maryanski, RN CIC, APIC New England Program Director

Our feedback following this course was absolutely outstanding! We hope that Evelyn will continue to educate the public and bring more awareness on safe injection practices so an event like this never happens again. Melissa Adams, Continuing Education Director, AZ Perio Dental Hygiene Study Club

 

 

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.

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@www.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.

 

Learning from our Mistakes: A New Model of Malpractice Resolution

Evelyn McKnight, president of HONOReform
Evelyn McKnight, president of HONOReform

“Dear sir or madam: you have been potentially exposed to Hepatitis C, Hepatitis B and HIV through unsafe practices by your healthcare provider. Please come to our facility to be tested.”

Those were the opening sentences of an official letter that I received from the Nebraska Health Department in 2002.

Thus began my involvement in malpractice litigation as a plaintiff.

But through this experience, we have developed a new model of malpractice resolution – one that requires not only compensation for the victim, but also safeguards the welfare of the community through remediation of medical error.

I was honored to share this model in a TEDx Omaha Talk last month. Please take a look at the talk, share it with your network, and join our campaign by following HONOReform Foundation’s Facebook page!

Methodist Monday – Leah’s perspective

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Leah Mittermeier, a Junior Level Nursing Student at Nebraska Methodist College, shares her perspectives on injection safety

Hearing Evelyn McKnight’s story really put into perspective what could go wrong if safe injection practices don’t take place. As a nurse I would feel so much shame in knowing my actions threatened people’s lives. I want to be as knowledgeable as possible with injections to ensure every patient I come in contact with is safe.

Being a patient safety advocate means speaking up anytime you see anything that could put a patient in danger. I know that it could be awkward confronting a colleague who was practicing unsafely, but at the end of the day, the patient’s safety and well being should come first. It is our responsibility as nurses to speak up for our patients. They might not realize that an unsafe practice is going on, so it is our responsibility to be on watch for anything threatening to the patient.

I’m very inspired to meet someone who had such a terrible experience and turn it into a learning opportunity for the world. I was impressed how calm Evelyn McKnight is after the experience and the fact that she doesn’t seem to hold grudges against the people involved.

Up to 1.5 million deaths, annually, caused by infections of viral hepatitis

Steve Langan, director of HONOReform, will attend the inaugeral World Hepatitis Summit
Steve Langan, director of HONOReform, will attend the inaugeral World Hepatitis Summit

We stand alongside our many colleagues throughout the world, including representatives of the WHO, one of whom, Dr. Stefan Wiktor, refers to hepatitis as the “silent epidemic.” Hepatitis is the seventh leading cause of death throughout the world Many of these cases of hepatitis, especially in developing countries, are caused by unsafe injection practices.

HONOReform is honored to be included in the inaugural World Hepatitis Summit, which will occur early next month in Glasgow. We are grateful to the World Hepatitis Alliance for including us in these meetings. HONOReform continues to seek ways to expand and provide injection safety education and awareness in developing countries. I will report back from these meetings. In the meantime, we encourage you to read about the proposed WHO-led pilot program--in India, Egypt and Uganda–to which we aim to lend the leadership of Evelyn McKnight and HONOReform’s experience, determination and voice.

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@www.HONOReform.org. Thank you!

Happy New Year!

Welcome back to the HONOReform blog, aka “Survivor Stories,” for our second full year of publication. We thank everyone who has had a role in making our blog a growing success—contributors and readers and everyone who has suggested to friends that they should check out our blog and pass it on to others.
And we encourage you to please continue to support our efforts.
Here at HONOReform, community-building is a key to emphasizing safe injection practices and doing all we can to educate the public and reeducate providers on the absolute necessity of injection safety.
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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.
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Sharing stories, transforming ourselves

Evelyn McKnight, president of HONOReform
Evelyn McKnight, president of HONOReform

In my work as a patient safety advocate, I have had the great good fortune of meeting many people who share with others their tragic story of how they were affected by unsafe healthcare. Like my family, their families were hit with a Mack truck on the road of life when they went to the doctor seeking better health, but came away with a worse medical condition because of unsafe healthcare. Telling the story may be gut-wrenching – it can be like living a nightmare all over. But through sharing their stories, these brave men and women are able to transform their experience into something useful, rather than simply a horrible personal trauma. Read more