Scot M. Silverstein, MD, is passionate about alerting the healthcare community to the patient safety risks posed by faulty electronic health records (EHRs) and the imperfect use of any EHR. That drive for patient safety was spurred largely by his own experience in trying to protect his mother when she entered a Pennsylvania hospital for treatment.
Despite his thorough knowledge of the risks she faced and his direct efforts to alert clinicians with whom he had personal and professional relationships, Silverstein’s mother succumbed to an error that he says was traced to a faulty EHR system.
Silverstein is adjunct faculty in healthcare informatics and IT at Drexel University’s College of Computing and Informatics in Philadelphia, PA. Largely as a result of his mother’s death, he also now is a consultant and independent expert witness in healthcare informatics, and he testifies on behalf of plaintiffs who claim malpractice related to EHRs.
These are the facts as outlined in the malpractice lawsuit involving Betty Silverstein:
Silverstein’s mother had a history of arrhythmia and a possible Wolff Parkinson White syndrome variant. He helped manage her care and, in April 2010, he became aware of an EHR failure at a large Pennsylvania hospital, concerning automatic updating, that threatened his mother’s safety.
As an expert in healthcare informatics and as a previous resident at the hospital, he wrote the CEO of the hospital to warn of the problem. There was no response, even though Silverstein and the CEO knew each other professionally.
He accompanied his mother when she was admitted to the emergency department (ED) of the same hospital on May 19, 2010, during which a triage nurse took a medication history. The medication history reportedly was entered into the ED’s EHR, the Pulsecheck system manufactured by Optum Clinical Solutions in Eden Prairie, MN.
The EHR already showed home medication data stored from prior visits to the ED, but this system required the triage nurse to affirmatively check a box next to the medication to confirm that it still was being used.
Sotalol 120 BID, a beta blocker that affects blood flow, appeared in the record from her most recent ED visit, and Silverstein was asked if his mother was still taking it. He confirmed she was. Silverstein then gave his mother’s complete medication history to the ED physician and ED nurse, which identified that his mother had been on sotalol for several years to prevent atrial fibrillation (AF).
With the previous error in mind, Silverstein says he was particularly vigilant in ensuring all aspects of his mother’s admission, including her medications, were reported properly and confirmed. Nevertheless, the ED records included no reference to sotalol. Silverstein’s mother was admitted to the ICU from ED for observation, and the faulty medication list from the ED EHR was passed on to the ICU record.
She did not receive sotalol in the hospital, though Silverstein was under the impression that it was being continued as one of her current medications. On May 22, the lack of sotalol caused Silverstein’s mother to go into uncontrolled AF, which she had not experienced in 10 years. The heparin administered to control the AF caused Silverstein’s mother to have a cerebral hemorrhage, his lawsuit claims. Only after the hemorrhage did her physician find out she had been on sotalol prior to admission, the lawsuit says.
After additional treatments, the patient died about a year later on June 6, 2011. The cause of death was attributed to the combination of medications needed to treat the new onset atrial fibrillation, which was caused by the failure to maintain sotalol therapy, the lawsuit maintains.
Silverstein sued the hospital and alleged that the EHR was faulty and was used improperly. Requiring the triage nurse to affirmatively check the box indicating sotalol still was being used was the opposite of how the system should have worked, he argued, and it did not use any type of confirmation dialogue asking “are you sure?” regarding a medication change.
“The triage nurse testified she thought she clicked the med to indicate my mother was still taking it and then hit ‘enter,’ but there was no confirmation dialogue asking if she really meant to discontinue the medication,” Silverstein says. “There also was no notification message to other team members that the triage nurse had discontinued a medication, giving them the chance to question it. In other words, the EHR allowed the triage nurse to practice medicine, intentionally or accidentally.”
The lawsuit is ongoing.
