CDC HIV/AIDS/Viral Hepatitis/STD/TB Prevention News UpdateMASSACHUSETTS: Patients Were Exposed to Hepatitis B Because Nurses Lacked Access to Electronic Medical Records
By Liz Kowalczyk
August 2, 2013
Boston Globe (08.01.2013)
A Massachusetts state health department investigation revealed that Boston Medical Center exposed 13 dialysis patients to hepatitis B because contract nurses did not have full access to computerized medical records. Officials are monitoring five patients who did not show immunity to the disease; to date, none has tested positive.
Staff members disinfect dialysis machines between patients, but they perform additional mandatory procedures, such as cleaning all internal tubing with bleach and heat, after treating a patient with hepatitis. Contract nurses working for private company DaVita relied on verbal information and were unaware one patient had hepatitis; the nurses used the same machine for two weeks on 13 other patients before another nurse discovered the error.
State investigators issued a “statement of deficiencies” and cited the hospital for violating regulations. According to the investigators, the hospital did not 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.”
The case exposed the possible dangers of using outside contractors who were unfamiliar with hospital procedures and computer systems. Hospital Spokesperson Jennifer Watson wrote in an e-mail that Boston Medical Center had “conducted a comprehensive review of the inpatient dialysis unit” and was working with DaVita to establish stronger procedural guidelines. The hospital told state investigators it now audited records every week to ensure proper disinfection of dialysis machines.