Dialysis patients at Boston Medical Center were exposed to hepatitis B in March because nurses lacked access to computerized medical records that would have told them one patient was infected, an investigation by the state Department of Public Health has concluded.
Because the nurses were unaware of that patient’s infection, they failed to properly clean dialysis machines before using them on 13 other patients over a two-week period. Equipment is supposed to be routinely disinfected before being reused on other patients. But extra measures, such as cleaning all internal tubing with bleach and heat, are required when a patient has hepatitis.
Five of the 13 exposed patients lacked immunity to hepatitis B and are being monitored in case they develop the disease. State investigators cited the hospital for violating regulations and issued a so-called statement of deficiencies.
Boston Medical Center contracts with DaVita, a private company, to run its inpatient dialysis unit, and the two nurses involved were not hospital employees. The hospital “failed to ensure’’ the nurses “received orientation and read-only access to the hospital’s computerized medical record system before being allowed to independently care for hemodialysis patients,” investigators said.
Instead they relied on verbal information that the patient was not infected with hepatitis B, which turned out to be inaccurate. Another nurse eventually discovered the error.
The case highlights the potential pitfalls of using “contract nurses,’’ who may not be as familiar with hospital procedures and computer systems.
Hospital spokeswoman Jennifer Watson said that so far, none of the five patients has tested positive for hepatitis B. She said the hospital believes this was a unique situation.
Boston Medical Center “conducted a comprehensive review of the inpatient dialysis unit, and we have worked with the vendor that provides the service to implement new policies and procedures,’’ she wrote in an e-mail.
Caregivers are now required to double-check patient medical information; additional nurses have been assigned to the unit to oversee the new policies; and all staff members have been trained and have full computer access to medical records. Workers involved in the episode were disciplined, according to the state report.
“We believe that these new safeguards will help ensure that patients receive the highest level of care at all times,’’ Watson said.
State investigators also noted that even though the dialysis staff did not know about the patient’s hepatitis B status for two weeks, work logs showed that the workers failed to follow even routine cleaning procedures during that time, including weekly disinfection of dialysis equipment with bleach, increasing the risk of contamination.
The hospital is now auditing records weekly to make sure staff members properly disinfect dialysis machines, hospital officials told state investigators.