In The Aftermath Of Sutter Health EMR Crash, Nurses Raise Safety Questions

Posted on May 24, 2018 I Written By

Anne Zieger is veteran healthcare branding and communications expert with more than 25 years of industry experience. and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also worked extensively healthcare and health IT organizations, including several Fortune 500 companies. She can be reached at @ziegerhealth or www.ziegerhealthcare.com.

In mid-May, Sutter Health’s Epic EMR crashed, accompanied by other technical problems. Officials said the system failures were caused by the activation of the fire suppression system in one of their IT buildings.

As you might expect, employees at locations affected by the downtime weren’t able to access patient medical records. On top of that, they didn’t have access to email or even use their phones. In addition, the system had to contact some patients to reschedule appointments.

On the whole, this sounds like the kind of routine issue which, though embarrassing, can be brought to heel if an organization does the disaster planning and employee training on how to react to the situations.

According to some nurses, however, Sutter Medical Center may not have handled things so well. The nurses, who spoke on condition of anonymity with The Sacrament Bee, told the newspaper that the hospital moved ahead with some forms of care before the outage was completely resolved.

The nurses told that when some patients were admitted after the systems failure, clinicians still didn’t have access to critical patient information. For example, a surgical nurse noted that the surgical team relies upon EMR access to review patient histories and physicals performed within the previous 30 days. According to Sutter protocols, these results need to be certified by the physician as still being valid on the date of surgery.

Instead, patients were arriving with their histories and physical exam records on paper, and those documents didn’t include the doctor’s certification that the patient’s condition hadn’t changed. If something went wrong during elective surgery, the team would’ve had to rely on paper documents to determine the cause, the nurses said.

They argue that Sutter Medical Center shouldn’t have taken those cases until the EMR was fully online. “Other Sutter hospitals canceled elective surgeries,” one nurse told a reporter. “Why did Sutter Medical Center feel like they needed to do elective surgeries?”

Also, they say that at least one surgical procedure was affected by the outage, when a surgeon needed a particular instrument to proceed. Normally, they said, operating room telephones display a directory of numbers to supply rooms or nurse stations, but these weren’t available and it forced the surgical team to break its process. Under standard conditions, the team tries not to leave the operating room because a patient’s condition can deteriorate in seconds. In this case, however, a nurse had to hurry out of the room to get instruments the surgeon needed.

While it’s hard to tell from the outside, this sounds a bit, well, unseemly at best. Let’s hope Sutter’s decision-making in this case was based on thoughtful decisions rather than a need to maintain cash flow.

Let this also be an important reminder to every healthcare organization to make sure you have well thought out disaster plans that have been communicated to everyone in your organization. You don’t want to be caught liable when disaster strikes and your staff start free wheeling without having thought through all of the potential consequences.