1

The patient perspective on public health protections for cancer patients

and HAI preventionEvelyn McKnight, AuD

www.HONOReform.orgwww.OneandOnlyCampaign.org

www.ANeverEvent.com

2

20022

Our story…

3

What the investigation found

• Improper port flush procedure

• Index case came to clinic in 2000

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

hospital claimed “no jurisdiction”• Unsafe practices for at least 16 months

4

What happened to the victims?

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

1 sexual transmission

6 deaths

5

What happened to the victims? 89 lawsuits

Community in conflict

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

6

What Happened to the Perpetrators?

7

www.ANeverEvent.com

Striving to prevent healthcare transmission of bloodborne pathogens

Hepatitis Outbreaks National Organization for Reform

9

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

10

• Programmatic funding• Congressional Briefing• GAO investigation• FDA, CMS, HHS & CDC collaboration• External Stakeholder Engagement (NQF, IHI)

11

Ten years later - 2012

12 and being counted!

Thank you for standing up