A network loop took down clinical applications at an academic medical centre for about four days, forcing a return to paper it had abandoned years earlier.
Sources checked when written 26 September 2026
TierThe network failed repeatedly for about four days; handwritten orders, photocopies and runners. Loss of phones is not documented. How tiers are assigned.
What happened
On 13 November 2002, a spanning-tree loop in the core network at Beth Israel Deaconess Medical Center brought down email, lab results, PACS images and order entry. The network failed repeatedly over about four days. Staff reverted to handwritten orders and prescriptions and used photocopiers and runners to distribute reports. Lab turnaround went from under 45 minutes to as long as five hours. The emergency department closed to new patients for four hours. Cisco engineers flew in equipment, and the PACS network was rebuilt overnight (Berinato 2003). The event was discussed in an NEJM Perspective (Kilbridge 2003), and ONC's SAFER Contingency Planning guide cites it.[1,2,3,4]
Documented harm
None documented in the source reviewed.
What it teaches
Network architecture is clinical infrastructure: a flat Layer-2 design is a single failure domain.
Disaster recovery that protects data but not the network leaves every application unreachable.
A single network fault can drop every clinical application at once, so plan downtime for the whole enterprise, not one system at a time.
Staff who have not used paper for years need practice, forms and runners ready in advance.
Treat network infrastructure as a managed clinical utility, with change control and current diagrams.
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