Thursday, October 06, 2016

From my totally nonprofessional viewpoint, it looks like at least the first two of these hospital deaths were directly related to bad health IT

The Connecticut "Health I-Team" site ( provides access to a database sourced from the Connecticut Department of Public Health that includes reports of violations at Connecticut hospitals found during inspections, as well as corrective actions taken to prevent similar future violations.

Their Mission Statement is as follows at

Mission Statement
The non-profit Connecticut Health Investigative Team [C-HIT] is dedicated to producing original, responsible, in-depth journalism on issues of health and safety, in Connecticut and the surrounding region.

Who We Are
A team of award-winning journalists, based in Connecticut, who have come together to provide the public with informative stories about health, safety and medical issues.

They've reported the following at, dated Oct. 5, 2016:

Several patient deaths, including the death of a newborn who was given an overdose of medication, were among various violations found at Connecticut hospitals, according to newly released inspection reports from state health officials.

The reports, which can be found in C-HIT’s Data Mine section, cover inspections that took place at hospitals statewide in late 2015 and the first four months of this year. Some of the violations detailed in the reports resulted in death and injuries to patients.

Department of Public Health (DPH) inspectors regularly make unannounced visits to all hospitals, during which they tour facilities, observe staff and examine documents. Though the most recently released reports document inspections that took place this year and last, some of the violations they include happened several years ago.

All hospitals where violations were found submitted corrective action plans that the DPH has accepted.

Several violations occurred at Yale-New Haven Hospital. A newborn admitted to the New Haven hospital’s Neonatal Intensive Care Unit from another hospital on July 8, 2015, died after being given too much amiodarone, according to DPH. The newborn had an irregular heartbeat and had failed the Critical Congenital Heart Defect screening soon after birth; the medication is used to treat irregular heart rhythms.

A physician assistant said the newborn may have been given too much of the medication because of a default frequency that was automatically entered in a computer system, according to the inspection report.

Also at Yale-New Haven Hospital, a patient having eye surgery on Jan. 16, 2015, died after having a heart attack during the procedure. DPH found the hospital did not document the patient’s vital signs or CPR efforts properly.

From my "totally nonprofessional" viewpoint (that's sarcasm, of course), it looks like at least the first two of these hospital deaths were directly related to bad health IT.

Yale is a relatively recent adopter of the EPIC EHR.

The true rate of near-misses and actual patient harms less than or equal to death is unknown, as random inspections and voluntary reporting are generally unreliable towards complete numbers.

However, based on voluntary evidence such as the ECRI Deep Dive Study (see, the rate is likely far higher than the simple stats reported above show.

The myths around electronic medical record systems have caused the expenditure of billions of dollars and the enrichment of the IT industry at the expense of healthcare.  Benefits are still dubious.  This money could likely have been better spent on healthcare provision itself, especially to the disadvantaged.

The patients mentioned above might be considered sacrifices to the narcissism of the cybernetic hyper-enthusiasts.

-- SS

Another observation.  Through my legal work I have now reviewed the current technical and user manuals to a number of EHR systems in both general and medical subspecialty areas. The nuances, complexity, arbitrary rules, "gotchas", workarounds, etc. of the software that needs to be learned and supported by clinicians (not to mention the technical support personnel) is staggering.  That is not even considering frequent changes.  This is increasingly frightening to me, a Medical Informatics specialist, considering clinicians have far more important matters to attend to, have little free time, and may need to learn multiple systems - sometimes in several hospitals.  These manuals make manuals to the most complex appliances (e.g., advanced professional digital cameras, or car repair manuals) seem like child's play.

Hospitals seem to be becoming a computer laboratory for cybernetic experimentation and a billing mill, rather than a patient care facility.  Clinicians are becoming "software buccaneers" for bad and overly complex health IT. 

All to replace a pen and paper forms.

This is not what the EHR pioneers who taught me Medical Informatics  intended.

-- SS

1 comment:

Anonymous said...

These deaths are the tip of the iceberg. HIT kills the innocent, the downtrodden, the wealthy. No one is protected from the sudden random toxic impact that these devices have on care and the doctors.