Newborn Dies After Ransomware Attack On Hospital

[MunoRN, RN]

A hospital in Alabama had no access to it's EMR and most of it's patient monitoring systems were not functioning for more than 3 weeks.  Despite this the hospital claimed publicly that it's ability to care for patients was not impaired and apparently continued to perform non-urgent cases and refused to divert patients who could be diverted.  

A delivery occurred where a nuchal cord went unnoticed (umbilical cord that strangulates a baby during delivery) due to the monitoring system being down (although it was still printing out strips).  The result was brain damage and the baby eventually died.

Ideally someone was still monitoring the strip printout, even though the monitoring system had effectively replaced the strip and was no longer part of the routine.  Although this occurred in an overall environment of what sounded like chaos and such errors seemed predictable without mitigating the risks.

Hospital Blames Doctor for Delivering Baby Amid Cyberattack After Child Dies, Mother Sues (MSN.com)

A Hospital Hit by Hackers, a Baby in Distress: The Case of the First Alleged Ransomware Death - WSJ

[JKL33]

https://s3.documentcloud.org/documents/21072978/kidd-amended-complaint.pdf

[Emergent, RN]

My first child was born at home with a lay Midwife in New Mexico, Elsie Sanchez. His cord was wrapped around his neck three times and she handled it just fine. Maybe if they open their eyes and monitored the old-fashioned way this newborn would not have died.

[MunoRN, RN]

7 minutes ago, Emergent said:

My first child was born at home with a lay Midwife in New Mexico, Elsie Sanchez. His cord was wrapped around his neck three times and she handled it just fine. Maybe if they open their eyes and monitored the old-fashioned way this newborn would not have died.

Nuchal cords are fairly common, occuring in up to 25% of deliveries, but the vast majority are non-strangulating.  

By "the old-fashioned way" are you referring to monitoring by watching the paper strip of a fetal heart rate monitor or something other than a fetal heart rate monitor?  

[MunoRN, RN]

19 minutes ago, JKL33 said:

https://s3.documentcloud.org/documents/21072978/kidd-amended-complaint.pdf

It seems part of the issue was that the monitor was only intermittently reading correctly.

I am by no means an L&D nurse, but my experience with the birth of my kids is that these monitors seem unreliable.  For those that work in L&D, is it rare to not have a good reading from a fetal heartrate monitor?

[klone, MSN, RN]

Yes, it's rare, and no, they're not unreliable. If their machine with paper strips was working, there is no reason why they could not have identified fetal distress.

Central monitoring wasn't even a routine thing until the last 15-20 years. And yet, millions of babies were born just fine prior to that. Blaming it on the ransomware is ***.

Sometimes central monitors go down. And sometimes there is "down time" where you have to chart on paper. That's not an uncommon thing. If they were not tracing the fetal heart rate on the paper, then they wouldn't have been tracing it on the central monitor, either. What's on the central monitor is exactly the same as what's on the paper. When central monitoring goes down, then you stay in the patient room, just like we used to do 15 years ago. And if it's not tracing well, then you put on an FSE. 

[JKL33]

Was waiting to hear from you @klone. My question is this (having pretty much no OB experience to speak of) -- is it unreasonable to think that a nurse would want to pretty much remain at the bedside for an induction without central monitoring capabilities? And/or is there a guideline for how often the strip would be reviewed in this situation?

[klone, MSN, RN]

WANT to? No. But that's kind of what you do if you don't have a central monitor. 

With Pitocin going, the nurse should be checking the strip and charting on it at least every 15 minutes. The thing is, it sounds like they didn't have a good strip, so there were long periods of time where the baby was not being monitored (which could be from fetal movement, or an obese woman). THAT is the issue, not the fact that central monitoring was down. IMO, this comes down to the nurse not paying close enough attention to her patient, and doing things to rectify it if she was not getting a good strip (which would be to put on an FSE).

[MunoRN, RN]

43 minutes ago, klone said:

Yes, it's rare, and no, they're not unreliable. If their machine with paper strips was working, there is no reason why they could not have identified fetal distress.

Central monitoring wasn't even a routine thing until the last 15-20 years. And yet, millions of babies were born just fine prior to that. Blaming it on the ransomware is ***.

I don't disagree that this was potentially avoidable with better mitigation of the effects of a down-system by nursing staff, although I'm skeptical that the risk wasn't someone increased by the lack of a support system that had become a part of the process of care.

I would guess these monitoring systems aren't cheap, so if they're unnecessary why did the hospital purchase and install it in the first place.

[klone, MSN, RN]

1 hour ago, MunoRN said:

I don't disagree that this was potentially avoidable with better mitigation of the effects of a down-system by nursing staff, although I'm skeptical that the risk wasn't someone increased by the lack of a support system that had become a part of the process of care.

I would guess these monitoring systems aren't cheap, so if they're unnecessary why did the hospital purchase and install it in the first place.

I never said they were unnecessary. They allow the RN to be able to watch what's going on without being in the room, and they offer remote capability so a clinician can pull up and look at the strip from home. They also allow for other eyes to be on the strip - the RN could be in the room doing fetal resuscitation on a patient with FHTs in the 60s, and the other nurses will see what's going on and come running to assist.

[Snatchedwig, BSN, CNA, LPN, RN]

Sounds like a staffing and mismanagement issue. If the monitoring system was down, there needed to be more nurses on to alleviate those "what if the nurse was in another patient room doing fetal resuscitation on a patient with FHTs in the 60s"

 

 

[SmilingBluEyes]

On 10/1/2021 at 6:31 PM, klone said:

Yes, it's rare, and no, they're not unreliable. If their machine with paper strips was working, there is no reason why they could not have identified fetal distress.

Central monitoring wasn't even a routine thing until the last 15-20 years. And yet, millions of babies were born just fine prior to that. Blaming it on the ransomware is ***.

Sometimes central monitors go down. And sometimes there is "down time" where you have to chart on paper. That's not an uncommon thing. If they were not tracing the fetal heart rate on the paper, then they wouldn't have been tracing it on the central monitor, either. What's on the central monitor is exactly the same as what's on the paper. When central monitoring goes down, then you stay in the patient room, just like we used to do 15 years ago. And if it's not tracing well, then you put on an FSE. 

Concur. I don't buy this. I did OB in hospitals w/o central monitoring  before they were a thing everywhere. No babies died during  my tenure in such hospitals. We watched the strips carefully. This is BS.