St. Rose Dominican Hospital AI sepsis alert recommends dangerous fluids for dialysis patient
An AI-driven sepsis protocol at St. Rose Dominican Hospital flagged a dialysis patient for IV fluids. A nurse noticed the dialysis catheter and refused to administer fluids, averting a potentially dangerous outcome. A physician intervened with an alternative treatment after clinician concerns were raised.
The AI failed to account for the patient's dialysis status, recommending a fluid protocol that risked pulmonary edema.
Key facts
- What
- An AI-driven sepsis protocol at St.
- Incident date
- Feb 1, 2026
- Who
- St. Rose Dominican Hospital
- Failure mode
- Agentic Action Error
- AI surface
- Agentic Workflow
- Severity
- High
What happened
An elderly woman arrived at St. Rose Dominican Hospital with dangerously low blood pressure. The hospital's AI system flagged her for sepsis and directed immediate IV fluids. A nurse noticed a dialysis catheter during examination and refused to administer fluids, averting potential pulmonary edema. Despite pressure from a charge nurse to follow the AI warning, a physician intervened with an alternative treatment.
What broke inside the model
- 01 · TriggerAn agent plans a multi-step task.
- 02 · Model stepIt chooses a wrong or destructive action.
- 03 · Control gapNo confirmation gate guards the write.
- 04 · FailureThe action commits to a system of record.
- 05 · ConsequenceData is changed or destroyed irreversibly.
A wrong action commits, and the step is written before anything can stop it.
The sepsis-prediction model did not account for the dialysis catheter, causing a fluid protocol that could have precipitated pulmonary edema. Clinician assessment intervened to override the AI and redirect treatment.
What it cost
Sources
Cite this entry
https://failureindex.ai/failures/rose-dominican-hospital-sepsis-alert-recommendsAI Failure Index. "St. Rose Dominican Hospital AI sepsis alert recommends dangerous fluids for dialysis patient" (FI-0189). Realm Labs. https://failureindex.ai/failures/rose-dominican-hospital-sepsis-alert-recommends (indexed Jun 5, 2026).Data fields CC-BY 4.0, prose citation permitted. Incident ID FI-0189. Full dataset at /data.
Note from Realm Labs, the Index steward
How Realm would have caught this
- Prism
- OmniGuard
- AgentRealm
Realm can sit inline on the agent's action path and require that a destructive or high-consequence action clears a real check before it executes, so 'delete and recreate' or a wrong write is stopped at the moment of intent, not explained in the post-mortem.