Two NGH patients were given emergency immunisations after unknowingly using the same blood cleaning machine as a man with Hepatitis B.
Alarm bells rang among Northampton General Hospital staff when it was discovered that someone having haemodialysis had a chronic case of the potentially fatal blood-borne disease and their machine had been re-used twice.
And a subsequent investigation revealed no routine blood screening had ever taken place at NGH for any patient before haemodialysis, although screening would take place if they were being sent on to the renal unit in Corby. An NGH spokeswoman said: “As soon as we became aware of the potential, albeit negligible, risk to the two patients they were immediately notified and were immunised. As soon as we identified the potential risk from a blood-borne virus the patient was isolated and allocated a specific haemodialysis machine.”
Membranes in the dialysis machine filter out waste products from the blood, which are passed out into the dialysate fluid.
In theory, the ‘dirty’ fluid is pumped out of the machine and the ‘clean’ blood is passed back into the body. The next patient then passes their blood through the machine in the same way.
As it happened, routine procedures meant the machine at the centre of the NGH alert had been cleaned after use by the Hepatitis B patient then cleaned once each day over five days before the two subsequent patients used it.
However, Department of Health guidelines state all patients should be tested for blood-borne viruses before haemodialysis. The NGH spokeswoman admitted this extra measure had not been taking place until the scare.
She said: “We have undertaken a thorough investigation following the near-miss in January 2013 as it is essential we learn from these events and make changes where they are needed to minimise risk.
“We know all our haemodialysis machines are routinely cleaned after use by each patient. In addition every machine is cleaned each morning, whether it is scheduled for use or not, to further reduce the risk to patients.
“The haemodialysis machine in question had not been used for five days in-between patients and, therefore, had been thoroughly cleaned five or six times before it was subsequently used by two further patients.
“The ward has undergone a full deep clean, including all ward equipment and trolleys to eliminate any other infection risk.”