Learning objectives: Nosocomial transmission of hepatitis B in hemodialysis units has dramatically decreased over the last three decades due to implementation of standard body fluid precautions and new protocols for isolating machines and staff in cases where a patient’s status was unknown. We present an example of a faulty protocol which led to the exposure of multiple patients to hepatitis B.
Case information: After a new patient’s first hemodialysis treatment, the machine was isolated for a complete wash run due to absence of hepatitis serologies. The isolation process was a piece of paper taped to the machine reading “Do not use.” During the morning shift, the paper fell off the machine. Due to no sign out to the next shift and a lack of signage, the machine was used on four patients in the afternoon. Upon discovery of the error, pre-dialysis serologies were reviewed and the patient was a chronic hepatitis B carrier. Exposed patients received HBIg.
Discussion: Hemodialysis protocols for preventing iatrogenic transmission of Hepatitis B include: vaccination of susceptible patient groups and staff for hepatitis B, frequent HBsAg testing, and physical separation of HBsAg-positive from HBV-susceptible individuals with use of separate staff, supplies, and machines. Several systems faults were identified in this case. This started with an inadequate isolation process of affected machines, i.e., a taped on sign that read “Do not use.” There was a lack of adequate signout between shifts. The machines themselves do not have a built-in mechanism that could have prevented this error. It is not known what the actual incidence of transmission through the semipermeable membrane is given the partition of the dialysate and blood compartments, but isolation protocols need careful attention and automated systems need to be developed that would remove the human error component.
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