By STEPHANIE McFEETERS
@mcfeeters
Daily Hampshire Gazette
WESTFIELD — After Noble Hospital staff members corrected a safety breach in April 2013, one or more of them failed to take the important next step — notifying senior hospital officials, according to the results of an internal investigation released Friday by Baystate Health and Baystate Noble Hospital.
Baystate officials on Friday apologized for that communication breakdown, which left nearly 300 patients unaware until last month that they faced a small risk of HIV, hepatitis B and hepatitis C because equipment used in their colonoscopies had not been adequately cleaned. Hospital officials stressed that they have taken steps to ensure the problem does not happen again.
“All indications are that this was a failure of process, and not one of ill intent, but it is a failure nonetheless,” Jennifer Endicott, the Baystate Health senior vice president for strategy and external relations, said in the statement. “And we genuinely apologize for it.”
On Jan. 20, Baystate Noble notified 293 patients who had colonoscopies between June 2012 and April 2013 that they faced a small risk of HIV, hepatitis B and hepatitis C, and encouraged them to get screened at no cost. Since then, patients have gotten blood tests and some have considered taking legal action.
Around two-thirds of the affected patients have been screened, Endicott said, saying it was too early to determine if any had been infected by the scopes.
A state inspection in December 2015 prompted the hospital’s announcement. The Department of Public Health is continuing to investigate the incident, spokesman Scott Zoback said Friday. He could not say how long the state investigation might last.
Noble Hospital got new colonoscopes in June 2012 but did not adjust its cleaning protocol until April 2013. Since the late January announcement, as patients have been screened, Baystate officials have been investigating internally to determine what went wrong.
Hospital officials say staff turnover and limited documentation have complicated the investigation. Baystate took over Noble in July 2015, nearly two years after the problem was discovered. In the statement released Friday, hospital officials did not address how the initial disinfection lapse may have occurred, but instead outlined how top hospital officials had failed to recognize the need to inform patients who had undergone colonoscopies about the possibility of infection.
Once Noble employees learned of the breach in April 2013, they acquired the proper equipment and coordinated with vendors to retrain staff, the statement said.
STERIS, which manufactures the equipment the hospital uses to clean its scopes, confirmed that the hospital sought help after discovering a disinfection error in April 2013. STERIS then provided Noble with the proper cleaning equipment and additional training, spokesman Stephen Norton wrote in an email.
Olympus, which manufactures the scopes, also provided additional training at the time, Baystate Noble spokesman Ben Craft previously told the Gazette.
Lapse in communication
At the time, hospital staff did not follow the “entire safety error process,” meaning the incident was not communicated to senior hospital officials, according to the statement.
The investigation suggests technicians notified their nurse manager, who in turn appears to have notified the nursing director, but that this message was not shared with wider hospital leadership, Endicott said in an interview Friday. Protocol calls for a broad, multi-disciplinary team to convene and discuss such an incident, but in this case that did not occur, she said.
“It’s very unclear to us what happened and how the process broke down,” Endicott said.
The statement explains that “there was no documentation to reflect the analysis that the team underwent, no documentation reflecting how and why the decision was made not to inform patients, and there was no escalation that would have included both the hospital epidemiologist and senior leadership.”
The failure to notify patients resulted from a communication breakdown, not an attempt to cover up an error, Endicott said.
Many patients were left with questions, and have considered taking legal action against the hospital.
John McQuade, an attorney with the Springfield law offices of Mark E. Salomone, said the firm has continued to take calls from affected patients, encouraging each of them to undergo screening. Friday’s apology, he said, again underscores that there was a “system failure” at Noble which undermines local trust in the hospital.
“Once you’ve harmed the confidence people have in you, it’s hard to bring that back,” McQuade said.
Still, he says it seems unlikely he can build a case against the hospital on behalf of any of the patients, as no one yet has been able to tie a serious injury to the procedure.
The investigation confirmed that the hospital has since implemented proper cleaning protocol and is “continuously using the most stringent and rigid high-level disinfection and storage processes at all entities across our health system,” the statement noted. Baystate has also worked to improve training, implement a “root cause analysis” process to investigate incidents and share its experience with other medical institutions.
As president and CEO of Noble Hospital at the time of the disinfection lapse, Ronald Bryant said he had no knowledge of the problem. “Human error does occur,” he said, noting that he is more concerned now with ensuring the hospital has proper systems in place. As part of Baystate Health, Noble now has access to greater resources, said Bryant, now president of Baystate Noble.
Echoing Bryant, Endicott said the hospital is focused on reinforcing its communication protocol and using the incident as a learning experience: “OK team, how do we make sure that never happens again?”
Stephanie McFeeters can be reached at [email protected].
