Full-service hospitals in Massachusetts disclosed 1,313 errors that harmed or threatened patients in 2015, marking a 60 percent increase in errors from the year before, the state health department reported. The increase is partially attributable to the recent woes of the dialysis unit at Baystate Medical Center in Springfield, according to The Boston Globe.
Of the disclosed errors, 26 cases involved surgical errors, 51 were instances when a medication error caused serious injury or death and 446 cases involved contaminated medical devices, drugs or biologics. In 2014, the latter category accounted for just 37 errors reported across the state.
In April, Baystate Medical Center notified 575 dialysis patients of potential infection exposure after state health inspectors found crowded and unsanitary conditions in the inpatient dialysis unit — they found Baystate staff did not isolate dialysis machines for use only on patients with hepatitis B and did not thoroughly clean those machines with consistency. Health officials also found Baystate exceeded the limits of dialysis patients that could be safely treated at one time.
The hospital offered affected patients free testing for hepatitis B and C, as well as HIV. Most of these patients were treated in 2015, and the Massachusetts Department of Public Health counted each one in its "serious reportable event" tally for the year.
Douglas Salvador, MD, vice president of medical affairs at Baystate, told the Globe none of the 575 notified patients were known to have contracted hepatitis B or C as a result of the errors. Hepatitis transmission was the primary concern after the errors were detected.
In regards to adequately cleaning the dialysis equipment, Dr. Salvador told the Globe thorough cleaning was consistently being done by the nurses, but the nurses often failed to document these efforts.
As for overcrowding, Dr. Salvador said, "There are people who come in through the emergency department and need dialysis services, and the desire is to do one more and try to get them done. There were a lot of good intentions."
According to Barbara Fain, executive director at Betsy Lehman Center for Patient Safety and Medical Error Reduction in Boston, annual fluctuations in the state's report provide insufficient indication as to whether or not medical errors in the state are trending upward.
The report only takes into consideration hospitals and surgery centers. Ms. Fain told the Globe. "That leaves out many other settings where we know serious medical errors take place, like doctors' offices and nursing homes. Without more complete data it's simply not possible to determine trends," she said.
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