Friday, March 04, 2011

Thanks to the wonders of EHR, this premature baby went to the grave, prematurely

Thanks to the distractions of EHR and the wonders of EHR auto entry, cut and paste etc., this premature baby went to the grave, prematurely:

Failures in care alleged after premature birth - $1,000,000 Settlement

By Virginia Lawyers Weekly
Published: October 18, 2010

Tags: Fairfax County Circuit Court, Medical Malpractice, Million-Dollar Settlements

Decedent and his twin sister were born healthy at 27 weeks gestation. Decedent was placed in the neonatal intensive care unit. Six days after birth, a peripherally inserted central catheter (PICC) was inserted into the right axilla and used to infuse nutrition, medication, blood products and lipids.

Within 48 hours, the PICC insertion site began to show evidence of compromise. The attending physician gave a verbal order to monitor the arm, but the order was never reduced to writing and no monitoring of the site was thereafter documented in the chart. Indeed, a comparison of the IV site care notes with the nursing notes revealed the use of an automated entry feature, confirmed by the defendants in discovery, which permitted the nursing staff to simply re-enter prior descriptions of a patient’s condition.

[Transforming medicine, one thunderous mouse click at a time, as expressed by the former HHS secretary. As at
this link on EHR risks re: copy and paste, "Another pitfall seen in litigation is the situation of an incorrect history or physical finding that is documented repeatedly in the medical record. This frequently occurs in the in-patient setting but can occur in the outpatient setting as well." - ed.]

As a result, the nursing notes continued to describe the condition of the affected arm as normal when in fact it was continuing to visibly deteriorate. Thereafter, despite swelling and seepage at the PICC insertion site and discoloration of the hand, the PICC was not removed for an additional 48 hours. The decedent was flown to another facility where the right arm was amputated after becoming necrotic and gangrenous. The infant died after 36 days of life. Plaintiffs sued the nurses, hospital and neonatal specialists charged with the decedent’s care.

Plaintiffs’ experts were prepared to testify that it was a departure from the standard of care for the physicians and nurses to fail to monitor the PICC insertion site and promptly remove the line when evidence of compromise and vascular damage developed.

[That's a no-brainer. Were these clinicians distracted by EHR clerical data entry duties, I wonder? - ed.]

They would have further testified that these departures caused a cascade of events leading to necrosis of the arm, the onset of gangrene and eventually staph sepsis, which killed the decedent.

The plaintiffs’ wrongful death claim was primarily for loss of solace. The decedent was survived by his parents and three siblings, including his fraternal twin. The decedent’s twin is now a healthy 2-year old who is meeting all normal developmental milestones.


Type of Action: Medical malpractice
Injuries Alleged:
Name of case:
Court: Fairfax County Circuit Court
Tried before:
Name of judge/mediator:
Special Damages:
Verdict or Settlement:
Amount: $1,000,000
Date: Sept. 17, 2010

Plaintiffs’ attorneys: Infant death Confidential Mediation Johanna L. Fitzpatrick $584,000 in medical expenses (contested by defendants) Settlement H. Jan Roltsch-Anoll, Woodbridge; Tracy C. Hudson, Manassas

What a tragedy.

-- SS


Anonymous said...

I have to wonder if an administrator considers this “just the cost of doing business?”

Steve Lucas

InformaticsMD said...


It was a case of Death Vader vs. Luke Skydoctor.

-- SS

Live it or live with IT said...

Did you get that information from

Anonymous said...

What is striking about this report is the failure to disclose the name of the hospital. Such disclosure would have benefit of alerting other families to be vigilant on all intricasies of the care of their loved ones, to protect them from the neglect of this sad case. Is there anyone out there aware of the hospital and EHR vendor?

the Black Swan

Anonymous said...

INOVA Health System has the only pediatrics hospital in Fairfax, Va. That system uses GE Centricity. Just an FYI.
CPOE has yet to be activated.

Peds Doctor