1 Evelyn McKnight, AuD www.HONOReform.org
www.OneandOnlyCampaign.org www.ANeverEvent.com A Look at a Never
Event and how it is Fostering a National Passion for Patient
Safety
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Learners will be able to describe 2 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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3 Our Story 3
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www.ANeverEvent.com 4
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5 What went wrong?
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A Never Event. Arbor Books, 2008. 6 What Went Wrong? Improper
port flush procedure
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7
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A Never Event. Arbor Books, 2008. 8 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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9 What Happened to the Victims? 6 deaths from HCV not cancer 33
antiviral therapy, 28 achieved SVR 1 sexually acquired HCV 11 died
of cancer, including 2 SVRs 89 lawsuits, $16M paid from NELF
Hepatology 2009; 50: 361-368
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10 Not just once, long ago 10
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Not just once, long ago 11 In past 11 years, 620 patients were
infected in 52 outbreaks 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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12 Outbreaks of bacterial infections associated with unsafe
injections, United States, 2001-2011 At least 25 outbreaks
identified/reported Majori ty in outpatient settings Common
breaches: Repetitive use of single-dose vials/saline bags, multi-
dose 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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13 What happens in Vegas
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Outbreak of Hepatitis C at Outpatient Surgical Centers,
Southern Nevada Health District,12/09 14 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
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happens elsewhere! 15 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
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Basic lack of infection control 16 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 patients catheter
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This will NOT prevent infections! 17 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
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Unsafe injection practices result in: 18 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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19 Medical disaster Glenn from NE Byron&Amber from SD
Michael from OK
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20 Financial disaster Melisa from FL Johnny from NC Jill from
NE
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21 Emotional disaster Karen from NV Emil from NE Nurse from
OK
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22 Social Disaster The history of health care in Las Vegas can
be divided into two eras: the one before last years 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.
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23 Its hard to believe this happens in the US
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Anesthesiology News, Jan 2012 24 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
Survey,1/2012
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Premier Healthcare Alliance Survey 25 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
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Infection Control Assessment of ASCs pilot study in MD, NC
& OK 26 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
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Drug Shortages complicate the issue 27 Combining single dose
vials for reuse MDVs accessed with reused syringes or needles
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Request change of CMS rules re: SDVs 28 16 signatories,
including 6 MDs Led by Rep Whitfield (KY-R) Backed by ASIPP
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Letter to CMS states * BUT what about when they are NOT used?
29 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.
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AND 30 Am J Infect Control 2010;38:167-72. 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
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But we can do something about it 31
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Striving to prevent healthcare transmission of disease due to
unsafe injections H epatitis O utbreaks N ational O rganization for
Reform
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In 2011 15 presentations to 5000 people BUT 9 outbreak
notifications to 6000 people!
35 Safe Injection Practices Coalition Raises awareness about
safe injection practices 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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36 http://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf
www.ONEandONLYcampaign.org Based on Standard Precautions for Safe
Injection Practices
http://www.cdc.gov/ncidod/dhqp/pdf//Isolation2007.pdf
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37 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 Standard Precautions Highlights
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38 Provider education 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 www.ONEandONLYcampaign.org
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39 JAMA. 2010; 303:2273-79
http://www.cms.hhs.gov/SurveyCertificationGenInfo/downloads/SCLetter09_37.pdf
Infection control survey tool for certified/licensed
facilities
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40
http://www.cdc.gov/HAI/settings/outpatient/outpatient-care-guidelines.html
Guide to Infection Prevention for Outpatient Settings: Minimum
Expectations for Safe Care Infection prevention checklist for
outpatient settings: Minimum expectations for safe care
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41 Needed: A culture of safety Empowerment to stop colleagues
from unsafe practices
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42 Thank you! 42 Outbreaks continue to affect many people
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And you can help prevent them!
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44 Speak up when you see unsafe practices! Visit
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