In 2012, I was teaching a workshop in New Hampshire as a hepatitis C virus outbreak was making headlines. This outbreak was traced to Exeter Hospital. The cause was a “drug diversion” case. The surgical tech injected himself with controlled substances that were meant for patients, and refilled the syringes with saline. He had hepatitis C. To make matters worse, the patients were deprived of sufficient medication for sedation or pain control. 

A more recent hepatitis C outbreak occurred in Minot, North Dakota. More than 50 nursing home patients were infected with a genetically similar strain of hepatitis C. The cause was drug diversion and reuse of needles by a phlebotomist.

In A Never Event, one hundred cancer patients including Evelyn McKnight were infected with hepatitis C while undergoing chemotherapy. McKnight’s husband, a family physician, helped to uncover the outbreak. Evelyn co-authored A Never Event with attorney Travis Bennington, and the two co-founded HONOReform, an organization committed to safe injection practices.

The largest reported hepatitis C outbreak occurred in Nevada. In 2008, 63,000 patients were notified of possible exposure to HIV and hepatitis B and C after having surgical procedures at an endoscopy center in Las Vegas. At least 116 case of hep C were linked to this center, primarily due to unsafe injection procedures.

Outrageous? Betrayal? Criminal? Yes, yes, yes.

It’s up to health care facilities to fix this. However, we aren’t completely helpless. Hoping that we won’t be the next victim of a medical error is not enough—instead, take steps to reduce the risk. Here are some tips on how to reduce exposure to medical harm:

  • Stay healthy. The bottom line is that you are more likely to be hospitalized for problems that may be avoided by lifestyle changes. For instance, smokers are more likely to need hospitalization than nonsmokers are.
  • If you are going to have blood drawn or an injection, confirm that the needle and syringes are from unopened packaging.
  • Ask a friend or family member to be your advocate and to be at the hospital during medical rounds and nursing shift changes.
  • Bring a list of medications and supplements that you take.
  • Keep a notebook at your bedside. Write down everything that is told to you, the names of your doctors and nurses, medications, the times you took your medications, and all your questions.
  • Bring your cell phone and charger to the hospital.
  • Be sure your wristband is checked or your name is asked before you have a procedure or receive medication.
  • Speak up. Don’t be afraid to ask questions.
  • Trust your instincts. If something doesn’t feel right, mention it immediately.
  • Don’t take medication that doesn’t look familiar to you. Also, don’t take medication if you don’t remember your doctor prescribing without first getting a satisfactory explanation.
  • If you have a choice, do not go to the hospital in July when the new medical residents are just getting started.
  • Bring hand sanitizer with you and be sure everyone who enters the room has washed or sanitized their hands. The hospital provides this, but having a bottle nearby serves as an extra cue.
  • Show this list to those close to you, so they know your wishes in case you have an emergency hospitalization.
  • Appoint a trusted friend or family member to act as Durable Power of Attorney for Health Care. This gives written authorization for someone to act on your behalf should you be unable to speak for yourself.

For More Information:

A Never Event by Evelyn McKnight  and Travis Bennington


National Center for Patient Safety

National Patient Safety Foundation