Lack of EHR Training Results in Patients’ Exposure to Hepatitis B

A Boston hospital’s failure to train contracted dialysis nurses on its electronic health record (EHRs) system resulted in the exposure of 13 patients to hepatitis B, according to a Massachusetts health department investigation.

The nurses, who work for the dialysis contractor DaVita, reportedly had not been trained on Boston Medical Center’s EHR, and as such were not aware that a dialysis patient with hepatitis B had been treated at the facility. If they had been, the system would have alerted them to take extra disinfection measures when cleaning the dialysis equipment. Without the additional alert, nursing staff continued to use the inadequately disinfected equipment for a period of two weeks. Of the 13 patients exposed to the infection in March of this year, five of them lacked immunity to hepatitis B, the Boston Globe reported.

Due to their lack of training and access to the EHRs, the two DaVita nurses involved with exposures had to rely on “verbal information that the patient was not infected with hepatitis B, which turned out to be inaccurate. Another nurse eventually discovered the error,” the Globe reported.

Officials at Boston Medical Center have said they will audit dialysis center records weekly to assure that dialysis machines are being disinfected properly. Additionally, the hospital is implementing policies requiring caregivers to double-check medical information; is assigning new staff to oversee the new policies; says it is training all staff on the EHR system; and says it has disciplined staff involved in the hepatitis exposure, according to news outlets.


1 Comment

  1. It seems that the dialysis equipment should have been disinfected properly regardless of the HB status of the patient. If the disinfectant procedure was adequate to begin with, then the other patients would not have been exposed to HB.

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