Medical errors persist, despite increased scrutiny

*By Liz Kowalczyk Globe Staff

Problems detected in the dialysis unit at Baystate Medical Center in Springfield accounted for a large chunk of the increase in errors reported by the state’s full-service hospitals.

Preventable medical errors reported by full-service hospitals in Massachusetts grew 60 percent last year, a rise partly attributed to problems detected in a single hospital’s dialysis unit.

Hospitals disclosed 1,313 errors that harmed or threatened patients in 2015, including 26 cases when the wrong surgery or procedure was done on a patient; 51 instances when a medication error seriously injured or killed a patient; and 446 cases of contaminated drugs, devices, or biologics.

This last category, which accounted for only 37 reports in 2014, constituted most of the overall increase in reported errors.

Baystate Medical Center in Springfield notified 575 patients early this year that they were potentially exposed to infection after state inspectors, during a spot visit, found crowded and unsanitary conditions in the inpatient dialysis unit. Most of those patients received dialysis treatment in 2015 and the state Department of Public Health counted each one as a “serious reportable event.’’

Dr. Douglas Salvador, vice president of medical affairs at Baystate, said no patients are known to have contracted hepatitis B or hepatitis C, the primary concerns, as a result of the problems found in the unit.

During their January visit, health department inspectors found that the hospital did not follow proper infection control practices. Staff did not set aside dialysis machines for use only on patients with hepatitis B, and did not always thoroughly clean those machines before they were returned for use on other patients, investigators said. Dialysis is a treatment that uses a special machine to remove harmful wastes, salt, and excess fluid from the blood of patients with kidney failure.

Baystate also exceeded its limit of eight dialysis patients per shift by crowding patients between stations and using portable machines, increasing the risk of contamination from blood splattering, inspectors found.

Salvador said the hospital is now isolating machines for use only on infected patients and no longer exceeds the limit on patients. He said the machines were being cleaned thoroughly, but that nurses were not always documenting their efforts.

“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,’’ he said. “There were a lot of good intentions.’’

A case of contamination of equipment at a second, unidentifed hospital also contributed to the overall increase.

The state Department of Public Health tracks preventable medical errors and releases the data annually to encourage hospitals and other providers to improve the quality of care. Research studies show that as many as one-third of patients nationally are harmed during their hospitalization, health officials said. Hospitals and outpatient surgery centers also are required to report these errors to patients who are impacted and their insurers.

Most categories of preventable errors fluctuate up and down from year to year. The data “reported in Massachusetts doesn’t tell us whether medical errors are increasing,’’ said Barbara Fain, executive director of the The Betsy Lehman Center, a state agency focused on improving patient safety.

Errors could be increasing because of pressure to serve sicker patients more quickly. But more reported errors could mean hospitals are getting better at detecting problems. And facilities that report more errors are not necessarily providing inferior care; they may do a better job of spotting harm and then correcting problems.

Fain also pointed out that the state data include only hospitals and surgery centers. “That leaves out many other settings where we know serious medical errors take place, like doctors’ offices and nursing homes,’’ she said. “Without more complete data it’s simply not possible to determine trends.’’

According to the health department report, surgical errors, such as leaving an instrument inside a patient, increasingly occur outside of operating rooms, in radiology, labor and delivery, and inpatient units. Falls and pressure ulcers are the two most common types of preventable incidents in most years.

Notably, 59 ambulatory surgery centers reported just four errors last year. They do not have as much experience as hospitals in developing systems to identify and track serious problems, underscoring the difficulty of drawing conclusions from the numbers.

“We’re concerned about the low level of reporting by (surgery centers) and that’s the reason for our initiatives,’’ said Fain, whose organization has developed an online tool to help providers identify and report errors.

Fonte: The Boston Globe