Electronic Medical Record Error Leads To Accidental Discharge Of Sepsis Patient

Case Overview

This case involves an elderly male patient who was discharged from a hospital emergency room despite having lab results consistent with sepsis. Although the patient’s lab results triggered the hospital’s “severe sepsis warning” in the electronic medical record, these notifications were only received by the nurse, not the doctor. The nurse did not verbally communicate the sepsis warning notification to the doctor because he assumed the doctor was already aware. As such, the doctor never saw or heard the warning and the patient was discharged. The patient returned to the emergency room within 48 hours after discharge in full septic shock. He suffered a stroke and ended up in a coma. An expert in hospital administration was sought to address the proper protocols for staff when a patient like this presents themselves to the emergency room.

Questions to the Hospital Administration expert and their responses

What are the proper protocols for staff when a patient like this presents themselves to the ER?

The hospital should not have sent a patient with sepsis home. It was clear to the EHR that this patient had sepsis, it was clear to the nurse that this patient had sepsis and it should have been clear to the ED physician. This patient should have been put on medication immediately and this demonstrates airtight negligence.

What type of training should nurses receive on a hospital's electronic medical record system, with specific regards to notifications?

One system in particular, which allows user-defined alerts that are approved by hospital executives or by a committee at the hospital, is currently being replaced in many hospitals nationwide because it is not a good system. These type of medical record alerts can be overridden by the treating physician relatively easily, though they may require some justification and this type of documentation should be carefully sought in a careful review of the EHR.

About the expert

This highly qualified expert has four decades of experience in medicine and healthcare administration. He received his BS in Physiology from Oklahoma State University and his MD from the University of Oklahoma. He completed his residency at the University of Oklahoma and is Board Certified in Internal Medicine. He is a member of the IBM Health Care and Life Sciences Advisory Council, the Clinical Electronic Health Record Advisory Council, and the Association of American Medical Schools. He previously served as the Chief of Staff of the Veterans Affairs Medical Center in Oklahoma and Alabama, and he is the former Under Secretary for Health at the Department of Veterans Affairs. He currently serves as a professor emeritus and a professor of healthcare administration at a well known Oklahoma medical school.