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Today is Mother's Day.

I weep.

ED EHR of April 15, 2010

ED EHR of May 19, 2010

PSYCHIATRIC HISTORY: No previous psychiatric history.

SOCIAL HISTORY: Denies alcohol abuse, denies tobacco abuse. 

No Sotalol.

Sotalol had never been ordered.

She had the pallor of death about her.

Her CT looked dreadful, much like the stock image below: 


Posted by InformaticsMD at 6:06 AM 
I am sorry for what happened to your mother, especially on this day.


May 8, 2011 at 10:50:00 AM EDT Live it or live with it said...

Hugs for you Scot. Nothing I can think to write will comfort you. I am sorry this happened to your mother. May some good come from it someday.

May 8, 2011 at 11:38:00 PM EDT 
What a horrific experience from EHRs and CPOE. These devices are defective, unusable, error promoting, and obviously, DANGEROUS.

They should be recalled.

May 9, 2011 at 12:03:00 AM EDT Scot M Silverstein MD said...

It's not so much the devices but the people who design, implement and kvell about today's ill conceived and markedly deficient systems.


May 9, 2011 at 2:18:00 PM EDT 
I'm sorry for what happened - my own mother has just gone through a major procedure here in the UK where we've had a chequered history so far of healthcare IT and it's been a difficult time.

But it seems from your account that you can't tell how the 'system' broke down. I write about health systems in Europe - I'm aware that the medical error rate in the US has been higher than here for some time, and not just a function of new IT. I'm wondering if there is evidence of errors rising in the US with electronic records and other admin systems.

May 9, 2011 at 4:06:00 PM EDT 
Marc writes:

Sorry to hear about your own mother.

You ask a good question. With the HIT systems exempt from the federal reporting requirements that other medical devices are subject to (see my post here), it's hard to tell exactly what is going on. Even the FDA admits its data on injuries and death related to IT is likely just the "tip of the iceberg" and the Joint Commission admits there is a paucity of data on HIT-related medical errors as well (in aforementioned JC Sentinel Events Alert on health IT of 2009).

I can say the literature is not strongly and uniformly supportive of cybernetic improvements (e.g., see "HIT Reading List.")

On a personal note, I do not believe the error that happened to my mother would have occurred in the paper era.

How can I make such a claim?

I worked in that very same ED for several years prior to computerization. The error mode would have been very unlikely to have occurred, unless someone was using disappearing ink.


May 9, 2011 at 4:54:00 PM EDT 
Re: Marc

I can also add that the "system" broke down locally when hospital officials ignored my warning letter of observed deficiencies, one month prior to my mother's injuries from the type of deficiencies I warned of (e.g., impaired clinician-clinician communications).

On a larger scale, the "system" has broken down when the advice of the pioneers and other bona fide experts is ignored by the HIT industry, e.g., the National Research Council's 2009 report on HIT which is also in the reading list links.


May 9, 2011 at 5:09:00 PM EDT 

Why are the meds handwritten on the chart? Surely that's an obvious source of error? I peeked at my mother's charts - in fact a whole binder at the end of the bed - and they were all computer printouts from a brief look. Apart from a few large and obvious notes on a board at head of the bed.

One strength we also have in the UK is a tight integration between primary and acute care with IT in many regions.

May 9, 2011 at 6:21:00 PM EDT Linda MacDonald Glenn said...

So sorry to hear this, Scott. It is particularly frightening to hear this story from a physician.
I hope your story prevents this from happening to someone else.

May 9, 2011 at 8:34:00 PM EDT 
Dear Scott, Do you have any fear that you and your family may not get the best treatment at hospitals you may have criticized?

Not do you think that worse treatment is or was administered, but do you fear it, do you feel it might happen, do you worry about it?

May 9, 2011 at 8:47:00 PM EDT 

Why are the meds handwritten on the chart?

I do not know for sure. Perhaps in transition or interface issues between the ED EHR and floor EHR (they are from different vendors).

However it does not take Sherlock Holmes to note the identicalness to the ED list. Once the error occurred, it propagated itself and was missed by innumerable clinicians. I was present every day of the hospitalization as well. Nobody asked me about her meds.

Having worked in that ED, I would never have expected such an error. I also had trust in this hospital from my past experience. That trust was misplaced; it was based on memories of a past that clearly no longer exists.


May 10, 2011 at 1:43:00 PM EDT 

As I've not identified the hospital, I doubt it.

However, remember that hospital walls have ears, and still have people with integrity working at them.

Such retaliation could likely end up with people spending time behind bars.


May 10, 2011 at 1:48:00 PM EDT 
My sincerest condolences and sympathy for your tragic loss. Thank you for sharing a deep and personal tragedy.

May 14, 2011 at 9:43:00 AM EDT