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How Employee Feedback May Have Prevented Deadly Meningitis Outbreak


According to the Centers for Disease Control and Prevention (CDC), there have been 590 cases and 37 deaths across 19 states caused from an outbreak of fungal meningitis among patients who received contaminated steroid injections. The main focus of the national investigation on this disaster is the New England Compounding Center (NECC), a pharmacy in Massachusetts. While it is the only location implicated in the widespread contamination in 2012, ex-employees of Ameridose, a drug-manufacturing organization that has some of the same owners of the NECC, have come forward with some shocking claims.

One ex-quality control technician at Ameridose stated that he was overruled by management when he tried to stop the production line when he spotted missing labels, according to an October 2012 article in The New York Times, while another employee (ex-pharmacist) said she resigned because she was “worried that unqualified people were helping to prepare dangerous narcotics for use by hospitals.”

Hearing reports like this must come as a shock to well-meaning corporate leaders who cannot be in all places at all times. So what can be done to avoid situations like this? And how can executives in other companies and organizations prevent such a costly tragedy? One of the first steps is creating and maintaining a company culture and work environment in which open communication is encouraged.

Employees should feel comfortable to share their concerns on policies and practices particularly those relating to safety and compliance. From what many news articles state, employees had strong concerns about business practices at both NECC and Ameridose. These specific safety issues could have been addressed prior to the meningitis outbreak. If current employees are hesitant to talk, HR should also be conducting exit interviews, particularly in high-risk occupations like healthcare, to identify any areas that may put the company, its customers and consumers at risk.

Managers need to be trained on the importance of balancing business needs with safety and to take frontline employees concerns seriously. In fact, HR in high-risk industries should implement a variety of avenues/opportunities for employee feedback, such as phone hotlines, online and on-site suggestion boxes, employee surveys, focus groups, new hire surveys and exit interviews.

At this point in the process, HR should analyze the data and information for trends and share important findings with senior management along with recommendations. HR can facilitate discussions and task forces for planning and next steps. HR should also be involved with safety committees, training and employee development and company mentoring programs. Both 1:1 and group mentoring are helpful in high risk workplaces for knowledge sharing on everything from quality control and technical skills to how to maneuver through corporate politics and the proper channels to voice concerns.

Employee feedback needs to be gathered systematically in such a way that it moves from being anecdotal stories (often attributed to a few disgruntled employees) to shining the light on specific, objective trends. Even with stringent safety regulations in place, companies in industries in which employee error creates a life or death situation should have additional safety processes in place.

Consider the case of the air traffic controller at the Honolulu International Airport who “mistakenly directed the JAL and the UPS jets on a collision course. At one point, their altitude separation dropped to 0, meaning they were headed straight for each other, traveling hundreds of miles an hour with about one and a half miles between them." It was discovered in the FAA investigation that the controller had told his managers he didn’t feel he was ready for certification, and had in fact, requested additional training via his training team.

From an HR perspective, this kind of information should come out long before an incident occurs. Those current and former employees have the information – it’s up to HR to gather it and help solve the problems that could lead to catastrophe. In the contaminated steroid tragedy, if HR had identified that safety was being set aside in favor of speed and other corners were being cut, they could have made a case to senior management for why this was bad from not just a consumer safety standpoint but also from a business perspective. And 37 people would still be alive.

Originally published in Great Leadership on Dec. 27, 2012: link

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