How Employee Feedback May Have Prevented Deadly Meningitis Outbreak

Guest post by Beth N. Carvin:

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

Beth N. Carvin is
President and CEO at Nobscot Corporation (, an HR technology company that specializes in key areas of employee
retention and development. She has more than twenty years of experience in
human resources, staffing, business management, sales and marketing. Beth is a
nationally recognized expert on employee retention and exit interviews, and has
assisted with exit interviewing strategy for large, multi-national companies,
in every industry, and in more than 20 countries. She
can be reached at