Boston Medical Center patients were exposed to hepatitis B because nurses lacked access to electronic health records, according to an investigation by the Massachusetts Department of Public Health, the Boston Globe’s “White Coat Notes” reports.
Investigation Findings
The investigation found that because nurses were unaware that one patient was infected with hepatitis B, they failed to properly clean dialysis machines before using them to treat 13 other patients.
Boston Medical Center contracts with DaVita, a private company, to manage its inpatient dialysis treatment. The two nurses involved in the case worked for Da Vita and were not employees of the hospital.
According to state health officials, the hospital “failed to ensure” that 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.”
Corrective Action
The hospital said that it is monitoring five of the 13 exposed patients who lacked immunity to the infection.
Jennifer Watson — spokesperson for Boston Medical Center — said that none of the patients have tested positive for hepatitis B so far.
She also said that the hospital has “conducted a comprehensive review of the inpatient dialysis unit” and is working with DaVita “to implement new policies and procedures,” such as:
- Providing all staff members with full access to and training for EHRs;
- Requiring nurses to check patients’ medical information twice; and
- Assigning more nurses to the unit to oversee new policies (Kowalczyk, “White Coat Notes,” Boston Globe, 8/1). Source
