FOR IMMEDIATE RELEASE

Contact: Brendan Monahan (Baystate Health)

(413) 794-5465
(413) 537-4063

Brendan.Monahan@baystatehealth.org
@Baystate Health

Baystate Health and Baystate Noble Hospital Announce

Findings of Internal Investigation Following 2012-13
Colonoscope Disinfection Concerns
WESTFIELD, February 5 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 bloodborne diseases.
At the time of the announcement last month, Baystate Healths 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 completedwhich 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 were 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.