Transcript A "Never Event"

A Look at a “Never Event” and how
it is Fostering a National Passion
for Patient Safety
Evelyn McKnight, AuD
www.HONOReform.org
www.OneandOnlyCampaign.org
www.ANeverEvent.com
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Learners will be able to describe…
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how reuse of syringes and multi-dose vials
can lead to patient to patient transmission
of bloodborne pathogens
how a large scale healthcare associated
hepatitis outbreak affects how the public
accesses healthcare
two patient outcomes of the Nebraska
Hepatitis C outbreak
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Our Story
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www.ANeverEvent.com
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What went wrong?
What Went Wrong?
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Improper port flush procedure
A Never Event. Arbor Books, 2008.
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What Went Wrong?
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Improper port flush procedure
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Index case came to clinic in 2000
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Complaints from housekeeping,
pharmacy, lab, nursing and patients
“No jurisdiction”
Unsafe practices for at least 16 months
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A Never Event. Arbor Books, 2008.
What Happened to the Victims?
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6 deaths from HCV not cancer
33 antiviral therapy, 28 achieved SVR
1 sexually acquired HCV
11 died of cancer, including 2 SVR’s
89 lawsuits, $16M paid from NELF
Hepatology 2009; 50: 361-368
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Not just once, long ago
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Not just once, long ago
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In past 11 years, 620 patients were
infected in 52 outbreaks
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Majority of outbreaks (42 out of 51)
occurred in non-hospital settings
Thompson NT et al. Abstract #396. A review of
hepatitis B and C virus infection outbreaks in
healthcare settings, 1998-2008. Fifth Decennial
Conference on Healthcare-Associated Infections
2010.
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Outbreaks of bacterial infections associated with
unsafe injections, United States, 2001-2011
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At least 25 outbreaks identified/reported
Majority in outpatient settings
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Common breaches:
Repetitive use of single-dose vials/saline bags, multidose vials entered multiple times with non-sterile
syringes/needles, pooling leftover contents of vials.
Poor hand hygiene, aseptic technique, and improper
storage and labeling of medications.
htttp://shea.confex.com/shea/2010/webprogram/Paper2113.html;
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What happens in Vegas…
What happens in Vegas…
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2/2008 - 63,000 patients exposed
through syringe reuse at endoscopy
center
9 definite cases, 106 possible
Estimated cost of outbreak
investigation, response and testing is
$16-$21M
Outbreak of Hepatitis C at Outpatient Surgical Centers, Southern Nevada Health District,12/09
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…happens elsewhere!
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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
Basic lack of infection control
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Same syringe to administer medication
to more than 1 patient, even if the
needle was changed.
Same vial for more than 1 patient and
accessing the vial with a syringe that
has already been used to administer
medication to a patient
Common bag of IV fluid for more than
1 patient, and accessing the bag with a
syringe that has already been used to
flush a patient’s catheter
This will NOT prevent infections!
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Changing the needle, but reusing the
syringe
Injecting through intervening lengths of
intravenous tubing
Always maintaining pressure on the
plunger to prevent backflow of body
fluids
Noting lack of visible contamination or
blood
Unsafe injection practices result in:
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Untold human suffering
Distrust in healthcare system
Bloodborne viruses and other infections
Disciplinary actions against providers
Malpractice suits and other legal actions
A medical, financial, emotional
and social disaster
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Medical disaster
Glenn from NE
Byron&Amber from SD
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Michael from OK
Financial disaster
Melisa from FL
Johnny from NC
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Jill from NE
Emotional disaster
Emil from NE
Karen from NV
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Nurse from OK
Social Disaster
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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
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UNLV School of Public Health survey
after outbreak showed 57% of
respondents were less likely to get a
colonoscopy in Las Vegas.
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It’s hard to believe this happens in the US
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Anesthesiology News Survey,1/2012
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50 NY anesthesiology residents surveyed
49% sometimes used same vial for more
than one patient
25% did not always use a new syringe or
needle when drawing from a vial
8% had reused syringes on different
patients
Anesthesiology News, Jan 2012
Premier Healthcare Alliance Survey
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5446 respondents (89% RN or MD)
0.9% “sometimes or always” reuse a
syringe but change the needle for reuse of
a second patient
15.1% reuse a syringe to re-enter a
multidose vial and then
6.5% reuse that vial for use on another
patient (1.1% overall)
Am J Infect Control 2010;38:789-98
Infection Control Assessment of ASCs
pilot study in MD, NC & OK
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6% reused single use device
28% reused single dose vials for multiple
patients
21% reused fingerstick lancing device
32% failed to disinfect glucose meter
after each use
JAMA 2010;303(22):2273-2279
Drug Shortages complicate the issue
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Combining single dose vials for reuse
MDV’s accessed with reused syringes or
needles
Request change of CMS rules re: SDVs
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16 signatories, including 6 MD’s
Led by Rep Whitfield (KY-R)
Backed by ASIPP
Letter to CMS states…
“There is no evidence that
transmission of blood borne pathogens
during health care procedures continue
to occur because of the use of single
dose vials in multiple patients when*
appropriate sterile procedures are
used.”
* BUT what about when they are NOT used?
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AND…
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Single dose vials lack preservatives to
prevent microbial growth
Re-entry into vial introduces microbes
Microbial growth begins within 1-4
hours, exponential growth thereafter
Am J Infect Control 2010;38:167-72.
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But we can do something about it
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Hepatitis Outbreaks National Organization
for Reform
Striving to prevent healthcare transmission of
disease due to unsafe injections
In 2011
15 presentations to 5000 people
BUT
9 outbreak notifications to 6000 people!
Alliance for Injection Safety
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Congressional Briefing
GAO report
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Programmatic funding
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FDA, CMS, HHS &
CDC collaboration
Response to SDV
controversy
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Safe Injection Practices Coalition
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Raises awareness about
safe injection practices
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Aims to eradicate
outbreaks resulting
from unsafe injection
practices
AAAHC, AANA, APIC, BD, CDC, CDCF, Covidien, Hospira,
HONOReform, NACCHO, NE Med Soc, NV Med Assn,
Premier, MEDRAD, FDA; State Partners: NV, NJ,NY, NC
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www.ONEandONLYcampaign.org
Based on Standard
Precautions for
Safe Injection
Practices
http://www.cdc.gov/ncidod/dhqp/pdf//Isolation2007.pdf
http://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf
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Standard Precautions Highlights
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Use aseptic technique
Never administer meds from same
syringe to multiple patients
Do not reuse a syringe to enter a vial
Do not administer meds from single-dose
vials to multiple patients
Limit the use of multi-dose vials and
dedicate them to a single patient
www.ONEandONLYcampaign.org
Provider education
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Medscape and Epocrates CME
CDC guidelines for injections and
outpatient infection control
Injection safety resource center
Safe injection practices training video
Provider toolkit for training
Infection control survey tool for
certified/licensed facilities
JAMA. 2010; 303:2273-79
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http://www.cms.hhs.gov/SurveyCertificationGenInfo/downloads/SCLetter09_37.pdf
Guide to Infection Prevention for
Outpatient Settings: Minimum
Expectations for Safe Care
Infection prevention checklist for
outpatient settings: Minimum
expectations for safe care
http://www.cdc.gov/HAI/settings/outpatient/outpatient-care-guidelines.html
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Needed: A culture of safety
Empowerment to stop colleagues from unsafe practices
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Outbreaks continue to affect many people
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Thank you!
And you can help prevent them!
Here’s how you can help
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Speak up when you see unsafe practices!
Visit OneandOnlyCampaign.org
Sign up for e-newsletter at
www.HONOReform.org
Recommend us for a presentation
Recommend A Never Event to others
Write a review of A Never Event on
Amazon
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Thank you!
Any questions?
Evelyn McKnight, AuD
www.HONOReform.org
www.OneandOnlyCampaign.org
www.ANeverEvent.com
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