WESTFIELD — At least 25 patients who had colonoscopies at Baystate Noble Hospital plan to bring legal action for negligence after improperly cleaned scopes placed them at a small risk of contracting infectious diseases. A report filed by the hospital with the state health department last week notes that the incident was “clearly preventable.”
Since Baystate Noble Hospital announced in January that a disinfection lapse several years ago left hundreds of colonoscopy patients facing a small risk of HIV, hepatitis B and hepatitis C, 243 of the 293 potentially affected patients have been tested.
“To date there is no evidence of any transmission of illness from the endoscopes,” Baystate Health spokesman Ben Craft wrote in an email Wednesday. He declined to say whether any patients had tested positive for HIV, hepatitis B or hepatitis C.
Noble Hospital, which joined Baystate Health in July 2015, acquired a new Olympus colonoscope in June 2012 but did not properly adjust its cleaning method to account for the scope’s auxiliary water channel until April 2013, when it acquired adapters needed to connect this part to the STERIS cleaning device.
The lapse came to light following a Massachusetts Department of Public Health visit to the hospital in late December 2015 prompted by an employee complaint, DPH spokesman Scott Zoback said earlier this year.
In January, Baystate Health told 293 patients who had colonoscopies at Noble between June 2012 and April 2013 that they faced a small risk of contracting HIV, hepatitis B or hepatitis C and offered them free testing.
Springfield attorney Robert DiTusa said Wednesday that he is aware of “several people” who have since tested positive. His firm Alekman DiTusa is representing at least 25 patients planning to bring legal action against the hospital.
Craft said Baystate Health cannot comment on the litigation.
DiTusa said these claims could come in two forms. Patients could sue for emotional distress, considering the “ordeal” they went through — being told they may have contracted a disease, getting tested, waiting for results and telling significant others to whom an infection could have spread.
“People have had a pretty severe emotional reaction to that,” DiTusa said.
And those who tested positive for an infectious disease could bring a “much more serious claim” against the hospital, DiTusa said, “for falling below the standard of care expected of hospitals in our community.”
Adding to patients’ frustration, DiTusa noted, is the revelation that Noble Hospital staff knew of the disinfection lapse and potential risk of disease transmission in April 2013 but decided against telling patients.
“You have to question their motivation for not telling patients of a risk, even a small risk, that they had been exposed to a life-altering disease,” DiTusa said. “As a patient, wouldn’t you want to know?”
This decision not to notify patients is made clear in a Serious Reportable Event report filed with the state and sent to an affected patient, a copy of which DiTusa provided the Gazette.
In an interview with the health department, a former operating room manager at Noble stated that “she and her supervisor brought the occurrence to leadership who conferred with the manufacturer and were told that the risk of transmission of pathogens through this port without final phase cleaning was very small,” the March hospital report states. “A decision was made that patients did not need to be notified of the risk of infection or advised to have testing done at that time in 2013.”
Though the hospital does not have a record of this communication with Olympus, Craft said officials believe the assurance was conveyed in a phone call. He acknowledged, as Baystate leadership did earlier this year, that “there were clear breakdowns in our process.”
The report notes that “this event was within the facility’s control” and “unambiguously the result of a system failure.”
“Root cause was identified as failed communication at the time of the purchase of the colonoscope in June 2012 between employees of Noble Hospital and the manufacturers and failure to properly analyze and identify the risk to patients at the time of discovery of the occurrence in April 2013,” it states.
Since learning of the lapse, the hospital has made several changes to prevent such an event in the future. According to the report, these include training employees who reprocess endoscopes when they start and then again twice a year, evaluating their competency, keeping detailed records of this information and reviewing procedures on an annual basis.
After sending out two rounds of letters encouraging the potentially affected patients to get blood tests, the Westfield hospital began the last stage of its outreach earlier this week, following up with phone calls. Baystate has until April 22 to show the state it made a “good-faith effort” to contact all patients who may have been affected by the lapse and offer them testing.
Stephanie McFeeters can be reached at smcfeeters@gazettenet.com.
Baystate Noble Incident Report — March 28, 2016 by GazetteNET
Baystate Noble Incident Report — March 28, 2016 by GazetteNET