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.
Question(s) For Expert Witness
- 1. What are the proper protocols for staff when a patient like this presents themselves to the ER?
- 2. What type of training should nurses receive on a hospital's electronic medical record system, with specific regards to notifications?
Expert Witness Response E-026526
I teach an EHR healthcare administration course. It is not likely that administrative protocols are a major factor in this case, other than the electronic medical record alert, which is most likely a user-defined protocol based upon lab results and possibly vital signs. 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. That being said, it is more likely that this case is one of negligence on the part of the treating ED physician. If the intent is to name the hospital as a co-defendant then it would imperative to review the relationship between the emergency medicine physician who treated the patient in the ED and the hospital. A significant majority of hospitals contract for ED physician coverage, and if this is true in this case, then the hospital would share equal liability for the adverse outcome. 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.
Expert Witness Response E-023880
I have served as the physician lead, credentialed physician trainer and chief medical officer for a major a veteran medical center. I’ve not seen a staff fail to read and react as they did here. First, the hospital mis-implemented the EHR if only the nursing staff got this warning. Second, the nursing staff should have questioned the discharge after receiving the warning. That would have put the physician on notice. Third, I assume the physician reviewed the lab results and it would be standard for those results themselves to display the warning even if the system did not push it to the doctor automatically. With regard to notifications, here the nurses got a warning so it should be standard nursing practice to react to it. From these facts, they seem to have done nothing because they assumed the doctor knew and chose not to react. That is a breach of the standard of care.