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Multiple Hospital Errors Result in Hepatitis B Exposure



A recent incident involving exposure to the potentially fatal hepatitis B virus raises concerning questions about access to information in the age of electronic medical records.

Earlier this year, thirteen dialysis patients at Boston Medical Center were exposed to hepatitis B when nurses failed to properly clean the dialysis machines after using them on a patient who had the blood-borne disease.  The tubing was supposed to be thoroughly sterilized with bleach and heat after use on hep B patients, but the nurses weren’t aware of the patient’s medical status, and so didn’t do the required cleaning.

Actually, the Massachusetts Department of Public Health found a number of problems that contributed to the exposure.

The contract nurses running the equipment worked for a private company hired by Boston Medical Center to operate its dialysis unit.  They weren’t given proper orientation or access to the hospital’s electronic medical records system, and so weren’t aware that one patient had hepatitis B.  Instead, they relied on an inaccurate oral report, without checking the medical records.  But worse still, the contract nurses didn’t even do the weekly routine cleaning of the machines–let alone the more thorough disinfecting required after use on a hepatitis B patient.

Fortunately, none of the exposed patients have thus far come down with the hepatitis virus, although they continue to be monitored.  And certainly, these patients must have had some sleepless nights and fretful days because of the exposure, even if they never contract the disease.

The incident shows one of the pitfalls of electronic records, which may make crucial information more difficult to find and access.  Health care facilities need to ensure that their systems are designed so that critical details are prominently displayed, and that all the appropriate providers have access to the information. In the old days, paper records usually had colored stickers on the front to highlight allergies, communicable diseases, and other important health information, and their electronic counterparts need similar “can’t-be-missed” alerts.

Electronic records aside, the case still raises concerns about why the dialysis equipment isn’t cleaned as if every patient had a communicable blood-borne disease, just in case. Most patients would expect that medical equipment is always thoroughly cleaned, regardless of the health status of the previous patient.

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