Oracle Cerner system implementation risks future patient deaths, coroner warns

Doctors voiced concern over lack of Red-Amber-Green rating system, says report

A coroner's report into a death at a hospital in northern England has said patients are at risk unless concerns about the implementation of a new Oracle Cerner patient administration system are addressed.

In a report released earlier this month [PDF], Rebecca Sutton, assistant coroner, examined whether County Durham and Darlington NHS Foundation Trust should take further action to prevent more deaths following that of Emily Harkleroad in December 2022.

The 31-year-old died of pulmonary embolism – a blood clot affecting the lungs – which the coroner said could have been prevented on the balance of probabilities.

Sutton drew attention to the recent implementation of an Oracle Cerner electronic patient record (EPR) system as a matter of concern.

The trust and Oracle Cerner first announced the shift to new EPR software in January 2021.

In October 2022, a new computer system was introduced into the Emergency Department of the University Hospital of North Durham, one of the trust's healthcare units.

Sutton said she was told the previous software system included a Red-Amber-Green (RAG) rating system, which was an "effective tool in quickly identifying patients requiring urgent oversight by senior clinicians, especially when the Department was under extreme pressure."

The RAG system on the previous software "ensured that the acuity of the patients was easily identifiable by looking at a single page on a display screen," the coroner said.

However, the new software did not. "Instead, the Cerner software has symbols next to patient's names that, when clicked on, provide an indication of the level of acuity of the patient, but not a clear indication at first glance," she said.

"I was told that concerns about the absence of a RAG rating type system had been raised by a number of clinicians, but that the response, thus far, had been that the new system does not have that functionality."

Especially in times of extreme pressure on the Emergency Department, a "quick and clear way of identifying the most critically ill patients is an important tool that could prevent future deaths," Sutton said. "In my opinion there is a risk that future deaths could occur unless action is taken."

The Register has contacted Oracle to give it the opportunity to respond. A spokesperson for County Durham and Darlington NHS Foundation Trust said: "We send our sincerest condolences to Emily's family and take the findings of this report extremely seriously. We will be responding to the coroner within the required timescales and it would be inappropriate to comment further whilst that process is ongoing."

The incident is not the first case in which Oracle Cerner software has potentially threatened patient safety. Computer errors following the go-live of its electronic health records system harmed nearly 150 patients at a Washington hospital, the US Senate heard in July 2022. Four days after Mann-Grandstaff VA Medical Center in Spokane switched over to its new Cerner software, staff became aware of an "unknown queue" problem that had the potential to cause harm to patients, senators heard.

The rollout of the $10 billion system across hospitals run by the Department for Veterans Affairs has been paused until it has fixed problems in the systems already in use and reviewed the program. ®

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