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Baystate Health and Baystate Noble Hospital Announce Findings of Internal Investigation Following 2012-13 Colonoscope Disinfection Concerns

February 05, 2016

WESTFIELD, February 5th — Baystate Health and Baystate Noble Hospital are releasing the findings of an internal investigation following the use of improperly disinfected colonoscopes at Noble Hospital in limited procedures between 2012-13. Last month, 293 patients who underwent colonoscopies at Noble Hospital between June 2012 and April 2013 were notified that they are at risk of having been exposed to improperly disinfected colonoscopes and blood-borne diseases.

At the time of the announcement last month, Baystate Health’s priority in its response was ensuring that the patients affected received proper notifications, clearly understood how to undergo the recommended testing, and were provided the care and support that they deserve. While this process continues, Baystate Health and Baystate Noble Hospital have at the same time conducted a thorough investigation to answer remaining questions about the problems, most importantly the lapse in time between the discovery of the improper processing in 2013 and notification of patients. The former Noble Hospital joined Baystate Health in July 2015.

The investigation has determined 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.

“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 colonoscopes 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.”

“We are very sorry for our mistake, and we’re committed to making it right and learning from it so we can continue to provide the very best care to our Westfield community,” said Ron Bryant, president of Baystate Noble Hospital.
Still, the investigation has confirmed that proper corrective action was successfully implemented in April 2013, and correct disinfection protocols have remained in place. The Massachusetts Department of Public Health has validated this information. Through this investigation, Baystate Health has committed to:

  • Continuously using the most stringent and rigid high-level disinfection and storage processes at all entities across our health system, including newly acquired facilities.
  • Continuously training and retraining our employees to provide them with the best possible information.
  • Collaborating with a newly hired chief nursing officer at Baystate Noble to continue ensuring proper practices and a safe environment for patients and staff alike.
  • Providing resources to ensure that full safety processes are implemented. As part of our policy, this includes a “root cause analysis” - which is an investigative process that determines the key factors that contribute to an incident with support from medical experts (such as a hospital epidemiologist), clear documentation that reflects analysis and decision making, and information escalation to senior leadership.
  • Sharing our experience with other medical institutions to prevent patients from this experience in the future.
  • A culture of transparency, apology, and resolution any time we fail to meet patient and family expectations.

“We apologize for this breach of trust, and we are committed to working with those affected and providing every support that we can,” said Nancy Shendell-Falik, RN, Senior Vice President for Community Hospitals for Baystate Health. “It is an honor to care for our patients, and we have taken this matter extremely seriously. We continue to work to strengthen our already robust standards for safety and quality across our health system, and we are committed to providing the excellent care that families up and down the region have come to expect.”