a never event: the patient's...

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A Never Event:The Patient’s Perspective

Evelyn V. McKnight, AuD

www.HONOReform.orgwww.OneandOnlyCampaign.org

www.ANeverEvent.com

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Our story – one of 130000 stories2

3 www.ANeverEvent.com

4What went wrong?

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• Improper port flush procedure

What Went Wrong?

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What Went Wrong?

• Improper port flush procedure

• Index case came to clinic in 2000

• Complaints from housekeeping, pharmacy, lab, nursing and patients

• “No jurisdiction”• Unsafe practices for at least 16 months

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• 6 deaths from HCV, not from cancer• 1 liver transplant, deceased 5/2010• 1 sexually acquired HCV• 33 antiviral therapy, 28 SVR’s• 11 died of cancer, including 2 SVR’s• 89 lawsuits, $16M paid from NELF

Mailliard, et al. Outcomes of a patient to patient outbreak of Genotype 3a Hepatitis C. Hepatology 2009; 50: 361-368

What happened to the victims?

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• Nebraska 2002• New York 2007, 2011• Nevada 2008, 2011• N Carolina 2008, 2010• Texas 2009• South Dakota 2009• New Jersey 2009• Colorado 2009• Pennsylvania 2010• West Virginia 2010• New Mexico 2010• Wisconsin 2010, 2011• Florida 2010• California 2011• Minnesota 2011• Mississippi 2011

40+ outbreaks in the past 12 years

Thompson NT et al. Abstract #396. A review of hepatitis B and C virus infection outbreaks in healthcare settings, 2008-2009. Fifth Decennial Conference on Healthcare-Associated Infections 2010.

10130,000 outbreak stories

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Medical Disaster

• Glenn from NE• Michael from OK• Byron from NE

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Financial Disaster

• Melisa from FL• Johnny from NC• Jill from NE

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Emotional Disaster

• Parents from CO and PA• Judy from NE• Nurse anesthetist from OK

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Social Disaster• The history of health care in Las Vegas

can be divided into two eras: the one before last year’s hepatitis C outbreak and the one after it.

-Las Vegas Sun, 3/1/2009

• UNLV School of Public Health survey after outbreak showed 57% of respondents were less likely to get a colonoscopy in Las Vegas.

15Thank you!15

Preventing the problem

We strive to prevent outbreaks

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Alliance for Injection Safety

• Congressional Briefing• GAO report

• Programmatic funding

• FDA, CMS, HHS & CDC collaboration

• External Stakeholder Engagement (NQF, IHI)

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Patient empowerment• Empowers patients to ask theright questions

Provider education• Medscape and Epocrates CME• CDC guidelines for injections and outpatient

infection control• Injection safety resource center• Safe injection practices training video

www.ONEandONLYcampaign.org

19Thank you!19

Outbreaks continue to affect many people

20 photography complements of Tom McKnight and Dean Jacobs

Could inadequate reprocessing lead to an outbreak?