Westfield, Mass. (WWLP) – Baystate Health has released the findings of an internal investigation into the use of improperly sterilized equipment at Noble Hospital in Westfield.
Last month, the hospital notified nearly 300 patients that they may have been exposed to blood-borne diseases during colonoscopies between June 2012 and April 2013.
The healthy system was looking into why it took so long to notify patients after the mistake was discovered more than two years ago. Baystate said proper corrective action has been taken and correct disinfection protocols are in place.
“All indications are that this was a failure of process, and not one of ill intent, but it is a failure nonetheless, and we genuinely apologize for it,” said Jennifer Endicott, Senior Vice President for Strategy and External Relations for Baystate Health. “While the likelihood of any transmission of illness from the colonoscopies is extremely low, Baystate Health is taking accountability for this situation and providing necessary resources to ensure all of our Baystate programs, facilities and services operate at the same high standard of care.”
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According to the news release sent to 22News from Baystate Health, the investigation found the following:
- Several of the individuals involved in the situation have moved on from their employment at Noble, which, along with failures in documentation, has presented challenges in fully understanding what took place during the period from June 2012 to April 2013. These former employees were willing to provide information to the best of their recollection.
- The investigation revealed that Noble employees, upon learning of the breach in safety, initially followed safety protocols and acted swiftly in correcting the issues. This included ensuring proper medical equipment was available and utilized, as well as working with medical vendors to conduct training exercises for staff.
- However, because the team involved did not follow the entire safety error process, the incident was not properly communicated to appropriate leadership levels of the organization, including senior executives. A “root cause analysis” was not completed – which is an investigative process to determine the key factors that contributed to the incident – 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.
- Upon correction of the deficiencies in process in April 2013, and because of this failure in the second part of the safety process described above, there was not appropriate recognition of the need to notify patients involved in those colonoscopies.