In 2015, hospitals in Massachusetts reported a total of 1,313 preventable errors. That figure is a staggering 60 percent increase over the number of preventable errors that were reported in the state in 2014. While that is bad news overall, the good news is that the increase is due mostly to the problems that were reported in only one dialysis unit.
In 2014, there were 37 reports of contaminated drugs, biologics, and devices. In 2015, that number soared to 446 cases. Other issues that were reported in 2015 included 51 medication errors that resulted in death or serious injury and 26 cases involving a wrong procedure or surgery being done on a patient.
The issue with the single dialysis center that sent the number of medical errors in our state so high occurred at Baystate Medical Center when patients were potentially exposed to unsanitary conditions that put them at risk of infection. The Department of Public Health counted each patient that was potentially exposed as a single serious reportable event. All in all, there were 575 patients who were notified of the issue; however, not all of those were patients in 2015.
The issue at this inpatient center is that no dialysis machines were designated for use only by patients who suffered from hepatitis B. The machines that were used were used on all patients and weren't always thoroughly cleaned. It was also noted that blood splatter was a concern because the center exceeded the limit of eight patients for each shift. The providers were using portable machines and crowding patients between the stations, which could have led to issues.
One good point about this report is that no patients have reported contracting the diseases that were of concern. In this case, the issues were hepatitis C and hepatitis B.
While it seems like disaster might have been averted this time around, these patients were all still put at risk. That is unacceptable. Any patient who is harmed in situation involving any medical error has the right to seek compensation for their harm.
Source: The Boston Globe, "Medical errors persist, despite increased scrutiny," Liz Kowalczyk, Aug. 24, 2016