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Book Review: A Never Event

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A Never Event is the chronicle of nearly 100 patients of the Fremont Cancer Center that were infected with hepatitis C through poor infection control practices and what I believe to be criminal actions of the nurses and physician running the clinic. I stumbled upon A Never Event while browsing through the Kindle Owners Lending Library. The cover image, a syringe, and risk management term, never event, piqued my interest and I was glad I made this download (note to authors: titles and cover art matter for ebooks).

857 Cancer Patients Exposed to Hep C

The book is told by one of the Cancer Center patients and a lawyer that represented many of the plantiffs in the litigation that followed the exposure of the hepatitis C outbreak. The book is essentially divided into two sections. The first half of the book tells the story of how the Fremont Cancer Center came to be in Fremont, Nebraska and the subsequent exposure of 857 chemotherapy patients that were exposed to hepatitis C.

Use A Never Event For Paramedic Education

Paramedic and nursing educators I would highly recommend integrating this story into your classroom. The shoddy infection control practices, disregard for patient safety, and failure to follow OSHA procedures are jaw dropping. I think the lessons learned in this book could become lessons applied for reinforcicng to students the importance of medication administration, sterile technique, learning and understanding dosage administration, and simply taking infection control procedures seriously.

The second half of the book is a series of profiles about the patients that were infected and their struggles to receive the proper healthcare for their hepatitis infection. The second half also digs into the difficulty of litigating on behalf of the infected patients due to structural failures in the Nebraska malpractice laws. Tort reform and caps on medical malpractice suits probably make a lot of sense until your neighbor or the farmer on the edge of town is infected with a crippling illness that quickly empties their savings and exhausts their health insurance life time caps.

Update October 2, 2012: Paramedic alledgly tampered with drugs and infected patients

This Didn’t Have to Happen

Many healthcare professionals witnessed and even reported the poor infection control procedures in the Fremont Cancer Center. Missing from the book was a discussion about specific actions that could:

  • Empower and embolden staff members to report poor infection control procedures
  • Instilling a culture where management takes those reports seriously, follows appropriate laws and standards, and thoroughly investigates any claims where patients and healthcare providers are endangered
  • Prepare any healthcare professional, regardless of their level of training or licensure, to call an all STOP! Flight medics tell me they have a phrase “all yes to go, one no to stay”. Although I am generally skeptical about the application of  this principle it is a cultural change that should be ongoing throughout healthcare.

HONOReform

Learn more about Hepatitis C outbreaks, hepatitis C and prevention from HONOReform the advocacy organization created by survivors of the Fremont Hepatitis C outbreak.

Injection Safety Video from One and Only Campaign