Dialysis patients at Boston Medical Center were exposed to hepatitis B in March because nurses lacked access to computerized medical records that would have told them one patient was infected, a state health department investigation concluded.
Because the nurses were unaware of that patient’s infection, they
failed to properly clean dialysis machines before using them on 13 other
patients over a two-week period. Equipment is supposed to be routinely
disinfected before being reused on other patients. But extra measures,
such as cleaning all internal tubing with bleach and heat, are required
when a patient has hepatitis.
Five of the 13 exposed patients lacked immunity to hepatitis B and
are being monitored in case they develop the disease. State
investigators cited the hospital for violating regulations and issued a
so-called statement of deficiencies.