A Never Event: Exposing the Largest Outbreak of Hepatitis C in American Healthcare History

by Evelyn V. McKnight, Travis T. Bennington

In the small, farming community of Fremont, Nebraska, townspeople eagerly welcomed an acclaimed doctor as the first full-time oncologist at the new, local cancer treatment center. But the fanfare soon turned into a nightmare. During chemotherapy treatments, 857 patients who were already waging the fights of their lives against cancer were inexplicably exposed to the deadly, blood-borne hepatitis C virus. At least ninety-nine of them contracted the lethal illness. The horror was unprecedented as this was the largest healthcare-transmitted outbreak of hepatitis C in American history, and remains so to this date. A Never Event - a term used to describe a preventable medical tragedy - is a searing account of the health challenges these patients encountered and their quest for justice, as well as the painstaking investigation to uncover the source of the outbreak. It s a story of recklessness, deception and betrayal by the person these patients should have been able to trust the their physician, a man who, when the outbreak was discovered, fled the US for his native country in the Middle East. Written by a survivor of the tragedy and an attorney who represented many of the victims, A Never Event is a wake-up call to medical and legal communities nationwide.

Genres: Nonfiction, Medical, Memoir, Medicine, Health Care, History

338 pages, Paperback

First published September 25, 2008

Reviews

[Jacquelyne · Rating 3 out of 5]

Overall a decent account of a public health outbreak. My biggest criticism involves the description of those at risk for hepatitis C. As a public health professional I found it abhorrent that they describe them simply as drug users or prostitutes, using archaic language to describe sex workers albeit this was written a while ago. Considering that this was written by people living in a smaller town in Midwest America this isn’t surprising however this type of stigmatizing language is problematic, judgmental, and not helpful.

[Mary Jo Mack · Rating 5 out of 5]

This book made me angry. Angry that such a tragedy could happen to innocent people in this day and time. Very angry at the doctor and his primary nurse that they so blatantly disregarded safe medical procedures...and to make it worse...they walk away without any punishment.

[M · Rating 4 out of 5]

this one falls into the “weird to assign stars but here we are” category. the legal part gets a bit tedious to read but its all vital information for the full extent to be understood and legal things are often tedious so that cant be held against the book itself too harshly. overall an eye opening story that definitely had me tearing up

[Carol Copeland · Rating 4 out of 5]

Interesting dilemma that was compounded by no one willing to be accountable to stop the physician perpetrator.

[Andrea Ketcham · Rating 5 out of 5]

So eye opening. Things you hear about-but when they’re in your backyard are even more alarming! Such a good read for any medical professional.

[Hannah Lehnert · Rating 3 out of 5]

A pretty good telling of the Hep C outbreak and how there was just time after time of people not taking action or disregarding what was going on. Biggest complaint with this book is that even though it goes on about how the patients didn’t want others to know they had Hep C because of the stigma surrounding it, it also completely played into that stigma and didn’t do anything to break that down. Some of the conversations as written seemed forced and unrealistic— I know part of this is because people don’t know the shorthand of different acronyms, especially local ones, but hearing “maybe we should try the university of nebraska medical center” instead of “maybe we should try UNMC” made me wonder about how much speculation they’re putting into these conversations. The authors admitted that upfront at the book, but it really makes me think about it more. Read this for a class, from Lincoln, NE.

[Marcia · Rating 3 out of 5]

I read this book on a Kindle Fire and the conversion of this book to the electronic format is horrendous. Page breaks occur in the middle of pages, text is jumbled, and many of the exhibits in the appendices are too small to read and the enlargment feature doesn't seem to be implemented.

I thought the book was informative but the conversion errors made it difficult to appreciate the points the authors were trying to make.

[Stephanie · Rating 5 out of 5]

4.5⭐️rounded up. Shocking, horrifying and unconscionable. How these nefarious actions of a greedy and unethical physician were able to go on for as long as they did is mind-boggling.
Highly recommend this book for all health care professionals. So glad my work book club put this on my radar.

While this is non-fiction, it is written in a way that it reads like narrative fiction with lots of dialogue.
The legal section wasn’t as easy to read as the medical section but I still took away the important facts.

A Never Event tells the real story of the largest (at the time) health care associated outbreak of
hepatitis C. The fundamental cause of this outbreak was reckless and sloppy nursing as instructed by the physician. After chronicling the events of the outbreak, the book shifts to the legal battle for compensation and licensure removal of those involved.
Dr. Javed instructed his nurse to use the same saline bag to flush lines on multiple patients (cheaper). This bag then cross contaminated every flush syringe.

So many things important takeaways.

1. The first nurse at the practice did everything the physician asked without questions. Even when this violated basic nursing practice
2.The physician should never have been the person instructing nurses on nursing practice or how to mix chemotherapy
3. A pharmacist should have been involved in the mixing of chemotherapy (at least providing education on safety procedures)
4.the clinic was associated with the hospital but it’s own entity— the hospital didn’t think they had jurisdiction over the actions of the provider even though they did. Several hospital staff knew of dangerous practices but only discussed it with Dr. Javed and documented what they knew.
5. Misunderstanding by many about mandatory reporting to the Department of Health and Human services
6. Poor nursing practice and training— nurses who didn’t stand up for what was right. Many nurses who floated from the hospital did refuse to go back. Should’ve been a huge warning flag.
7. Patients who spoke up weren’t taken seriously
8. Different labs used and no centralized way to see the cluster of hepatitis C cases early
9. Lack of follow through when questions were raised about nursing practices
10. Cancer patients are very vulnerable. There is real fear that speaking up may impact treatment. Some insurance companies mandate where a patient can be treated— patients may have felt they had no other option.

There were hints at medical fraud. Using less drug than necessary and improper billing that I wanted to know more about. This wasn’t the focus of the book. The authors provided enough information to show just how unethical and greedy Dr. Javed was.

After these patients were diagnosed, many decided to pursue legal action. They faced many roadblocks.
The fact that the state of Nebraska’s attorney general wouldn’t act on many legal aspects of this case was shocking. Victims had to ask to have the licenses of Javed and Prochaska removed. The state of Nebraska also has complicated malpractice laws that protect physicians (definitely value to this) but also make it difficult for victims tot get compensation.
One other thing that bothered me. The author herself had a cancer and hepatitis diagnosis. Her husband was a physician. Her diagnoses were given to him first and relayed to her. This violates privacy and was part of the of the problem in that clinic. The author didn’t seem bothered, but it struck me as a very odd way to provide test results.

Many in health care question all of the rules and regulations we follow. This book is a good reminder of why. Dr. Javed did state multiple times that things in a clinic setting are different than a hospital setting. Unfortunately there is some truth to that. Hospitals are held to the highest standards and must be reviewed by many accrediting bodies (CMS, JCAHO, board of health,etc). Basic health care safety standards still apply to clinics.

Had one or two people acted earlier, so many lives could have been saved. Because Dr. Javed seemed nice, his coworkers found these reports hard to believe and didn’t take the appropriate steps.

Reading this about this, I couldn’t help but see parallels to another different health care tragedy. The Larry Nassar sexual abuse case. In that case, again many medical and legal professionals failed to take action early. This lead to many young women being impacted.

A good reminder that ALL health care professionals have the responsibility to do what is right, follow procedures and ask questions if things seem unsafe.

[JeriLyn · Rating 4 out of 5]

A Never Event exposes a disturbing case of preventable medical harm—actions so reckless they fall under the category of “never events” in healthcare. The story centers around a cancer clinic where reused needles and poor infection control led to a hepatitis C outbreak. Hospital employees and executives knew of the problems in the clinic. Yet no one took action to stop it.

As a Nebraska resident, I learned many uncomfortable truths. The Excess Liability Fund limited the total compensation victims could receive and Nebraska law does not permit punitive damages in medical malpractice cases. This means that even in instances of egregious negligence or misconduct (i.e. this situation), plaintiffs cannot receive additional compensation intended to punish the wrongdoer beyond actual losses. Taxpayers were burdened with the costs of researching the outbreak, testing, communicating with patients, etc. while the individuals involved moved on without accountability. Tahir Javed became a Health Minister in Pakistan, and Linda Prohaska took a new job at an Omaha hospital.

These patients were kicked while they were down . . . . infected with Hep C while undergoing cancer treatments. On top of it, they were denied both justice and fair compensation. Despicable.

helped cover malpractice settlements, meaning public funds softened the fallout instead of holding individuals fully accountable. And because Dodge County owned the hospital, the lines of responsibility were blurred—raising serious questions about oversight and accountability.

[Nic · Rating 3 out of 5]

2 stars for the writing and up to 3 stars for the story.

I had been interested in hearing more details on this "never event" for some time. I'm dismayed this could happen in this day and age. There were many warning signs and opportunities to stop this train wreck, but it didn't stop until more than 1 patient acquired hepatitis C. In the end, close to 100 patients had acquired the virus, due to grossly shocking, unsanitary practices. Unfortunately, I'm aware how hospitals and their providers are well esconced within their bubble of lawyers and layers of protection from malpractice suits. Reading through all the court trials was tedious business. I enjoyed the included, informative chapter on hepatitis C. If you're interested in learning about the largest hepatitis C outbreak in American history, this is your book.

Dr. Javed...was offered over $1.3 million in potential incentives... 6

[Linda · Rating 5 out of 5]

Having gone to medical school in Omaha and visited Fremont often, I had to read this book. The individual stories are compelling. The lawyerly discussions are worth reading slowly - they’re actually written well for lay people. And the aftermath is worth pondering. A necessary read for medical professionals and patients alike.

[Laureen · Rating 5 out of 5]

Definitely worth reading!

While the ebook could use a copy edit, this book takes on an important topic and one that should have been handled far better by those we often (have to) trust most: doctors, nurses, healthcare administrators, insurance companies, and attorneys. Hope all nursing and Medical school students read this!

[Amanda Schultz · Rating 4 out of 5]

A crazy, true story taking place in small town Nebraska in the late 90s/early 00s. The first part is a narrative about the hepatitis C outbreak caused by an oncologist and his team in a clinic, written by one of the victims. The rest is written by an attorney involved in many of the victims' cases. It's a very good way to tell a story like this and an important story to tell.

[Lisa Leu · Rating 5 out of 5]

This book required reading for daughter in nursing school. She passed it on to me because it recounts a fairly recent Hepatitis C outbreak in a community not far from where we live. It is a medical tragedy and a trial that resulted from malpractice in one cancer treatment center.

[Lisa Wolter · Rating 5 out of 5]

A mistake unexamined, is a mistake repeated. This is a must read for people going into the health profession. It underscores proper nursing care and outcomes, when and how to report dangerous practices, and advocating for yourself as a patient and as a healthcare worker to always do no harm.

[Lauren Tien · Rating 3 out of 5]

I know this was not written by professional authors, but I really hated the use of quotes for exposition. No one talks like the people in this book. However, the events and content of the book are well worth knowing about.

[Raena Northrup · Rating 5 out of 5]

5⭐️ WOW!! I read this book for class and i have to say this is the most interesting non-fiction book i’ve ever read!! I can’t believe this happened so close to home, and the results of this outbreak sadden me so much.

[Daune · Rating 4 out of 5]

It was a well described retelling of events that caused an outbreak and the pursuit of compensation and reform

[Alexis Aghbashian · Rating 3 out of 5]

A sad but interesting true story that makes you question everything in the medical community!

[Lynn W · Rating 4 out of 5]

I read this several years ago. It was especially interesting to me as a nurse and as a resident of a nearby community.

[Michael Connolly · Rating 3 out of 5]

This books describes the victims of an oncologist whose unsanitary practices caused an outbreak of Hepatitis C in Fremont, Nebraska in 2001. Ninety-nine patients were infected. From reading the description of the oncologist, he sounds like a charming psychopath. Just because a person is smart, doesn't mean he is ethical. The oncologist tried to save money by reusing a saline bag for multiple patients, thus transmitting the Hepatitis C virus from one patient to another. Hepatitis C attacks the liver, often causing liver cancer and death. When the oncologist was found out, he fled to his native country. The oncologist was not an employee of the hospital where he worked, he merely rented space there for his oncology clinic, the Fremont Cancer Center. So the hospital did not supervise his work, and was not legally liable for his mistakes. Problems with his chemotherapy procedures were reported by several different people, but their reports were ignored. Because of the feudalism still present in medicine, nurses are subservient to doctors, and when they suspect something is not right, and they tell the doctor, and the doctor says that there is no problem, then the nurses usually figure that the doctor knows more and they should shut up. This situation is especially true when the doctor is a psychopath, because psychopaths try to surround themselves with passive, obedient staff. Neither the hospital nor the oncology clinic wanted to admit that mistakes were made, and they were reluctant to correct their loose safety standards. The book was written by one of the victims of the Hepatitis C outbreak and one of the malpractice attorneys. When settling the lawsuits, the guilty party tried to keep everything secret, rather than bringing the problem out into the open. The victims and their attorneys had to act heroically in order to achieve justice against a medical system that closes ranks around its worst practitioners. Even the state government of Nebraska acted against the interests of the victims, because it was trying to avoid liability. The state government had more powerful methods of discovery than private lawsuits, but the evidence that the state of Nebraska gathered never became public, because there was no hearing on the revocation of the oncologist's medical license. Instead, the oncologist voluntarily surrendered his license, so no hearing was required. The Hepatitis C problem has not gone away. Just this year (2012) there has been another hospital-caused outbreak of Hepatitis C, this time in Exeter, New Hampshire.

[Anne · Rating 3 out of 5]

A history of the Hepatitis C outbreak in Nebraska 2001, involving improper syringe usage at a chemo center, subsequently causing 99 patients to contract the virus in their immunocompromised state, causing a virus that could otherwise go unnoticed to kill rapidly. The physician that caused the improper usages flees the country and the nurses involved continue to practice in other hospitals. Meanwhile patients who had valiantly fought cancer had to endure even more horrific treatment regiments to try and rid their bodies of the virus. Not all were successful. This book also explains how the state of Nebraska's laws limited the victims rights and compromised the malpractice suits by governing the malpractice fund at a state level. Interesting and kept my attention.

[Susan Henson · Rating 5 out of 5]

One of the members of our book club is related to one of the authors and a surviver, Evelyn McKnight. She and her co-author, Travis Bennington, one of the attorneys in this "event" came and spoke to us. What a horrible series of preventable illnesses. The medical field at it's worst. THe book is told in a very personal and "story" kind of fashion. You really connect with the victims and families and even Travis in this unbelievable documentation. They have pursued even further righting these wrongs by establishing a foundation, and trying to activate a national initiative. I highly recommend this book. We should all be more wary and questioning of our care.

[Noreen · Rating 3 out of 5]

This book is very disturbing. An outbreak of Hepatitis C happened in Fremont, Nebraska in Fall of 2002. The shoddy practices of the nurse Linda Prochaska, and the unethical medical practice of the doctor of a cancer clinic were the source of the infections. But they were never charged with a crime. Unfortunately, the doctor escaped to Pakistan where he became the Minister of Health. And the nurse still works in health care. There were malpractice lawsuits, but the state of Nebraska has some whacky conflict of interest laws that added to the suffering of the victims. The purpose of the book is to shed light on this tragedy.

[Elizabeth Hicks]

Important event to know about- the largest out break of hepatitis in the U.S. due to incorrect practices in a medical clinic treating cancer patients. The first part of the book was written by a doctor and the second by an attorney.
It was heart breaking to read what the patients endured. Legal action was taken and the second half of the book was a bit tedious, but necessary.

[Elizabeth]

Evelyn V. McKnight will be speaking at Johns Hopkins on September 17, 2010.

[Jan · Rating 5 out of 5]

All health care providers need to take note.

[Jim Holscher · Rating 2 out of 5]

This book started out very promising. It got bogged down with innuendo at points along the way seemed to repeat itself.

[Jack · Rating 4 out of 5]

An interesting and detailed account of an outbreak of hepatitis caused by poor clinical practice. Disturbing to think it could happen in the 21st century.

[Traci Ahlbrandt · Rating 3 out of 5]

Being in the medical field and from Nebraska, I had to read this book. It's mind blowing that something like this happened and I enjoyed getting all the facts.