Medical error reduction hits a wall in Massachusetts

Further scrutiny isn’t moving the needle on medical errors in Massachusetts, where the rate of preventable errors grew 60 percent last year, according to The Boston Globe.

In 2015, hospitals in The Bay State revealed they made 1,313 errors. The mistakes included surgeons performing the wrong procedure on a patient and medication errors leading to death or serious injury.

But the biggest increase in errors was in the category of contaminated drugs and devices, which only led to 37 errors in 2014 but accounted for 446 cases last year, the publication reported. Much of the increase traces back to one specific dialysis unit at Springfield’s Baystate Medical Center, where 575 patients were informed they may have been exposed to infection earlier this year.

A January inspection by the Massachusetts Department of Public Health found Baystate Medical Center dropped the ball on numerous infection-control measures, according to The Globe. For example, dialysis machines used for patients with hepatitis B were not used exclusively for those patients, and in many cases staff didn’t thoroughly clean them before use on other patients. 

Douglas Salvador, M.D., vice president of medical affairs at the organization, told the newspaper that the hospital has since taken steps to remedy these issues, such as setting aside machines to be used exclusively on infected patients. Salvador insisted that machines were cleaned thoroughly, but said the fast-paced environment kept nurses from documenting everything.

“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 told the Globe. “There were a lot of good intentions.’’

Part of the problem is that public data in Massachusetts doesn’t make clear whether errors are increasing year over year, Barbara Fain, executive director of the patient-safety-focused Betsy Lehman Center, told The Globe. Pressure to serve sicker patients faster could be leading to more errors, but an apparent increase could also indicate hospitals are simply paying more attention, she said.

Providers seeking to make a dent in their error rates should also take such steps as engaging physicians and staff, standardizing protocols and creating a culture of safety.

- here’s the article