Breadcrumb

The New Electronic Health Record’s Unknown Queue Caused Multiple Events of Patient Harm

Report Information

Issue Date
Report Number
22-01137-204
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
National Healthcare Review
Report Topic
Electronic Health Records Modernization (EHRM)
Patient Safety
Major Management Challenges
Healthcare Services
Leadership and Governance
Recommendations
2
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
The Office of Inspector General (OIG) conducted a review to assess a safety concern with the new electronic health record (EHR) that resulted in patient harm. The OIG found that the new EHR sent thousands of orders for medical care to an undetectable location, or unknown queue, instead of to the intended location. Veterans Health Administration (VHA) identified and ranked safety concerns with the new EHR. In December 2021, VHA assessed the risk of the unknown queue as “major severity,” “frequently occurring,” and “very difficult to detect.” As such VHA recognized immediate mitigation was needed. Oracle Cerner failed to inform VA end-users of the existence of the unknown queue and put the burden on VHA to mitigate the problem. Beginning in June 2021, VHA staff spent substantial hours to complete clinical reviews to assess patient risk and harm related to the unknown queue and found that the new EHR’s delivery of orders to the unknown queue caused 149 patient harm events. In late 2021, VHA staff provided the Deputy Secretary and the Executive Director for VA’s EHR modernization effort with information on the unknown queue safety concern and identified patient harm. Each facility that goes live with the new EHR will require an ongoing commitment from facility staff to monitor and address the new EHR’s unknown queue. Cerner and VHA took actions to minimize orders being routed to the unknown queue. However, after finding over 200 orders in the unknown queue in May 2022, the OIG has concerns with the effectiveness of Cerner’s plan to mitigate the safety risk.

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Not Implemented Recommendation Image, X character'
to Electronic Health Record Modernization Integration Office (EHRM IO)

The Deputy Secretary reviews the process that led to Oracle Cerner’s failure to inform VA of the unknown queue and takes action as indicated.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Electronic Health Record Modernization Integration Office (EHRM IO)

The Deputy Secretary evaluates the unknown queue technology and mitigation process and takes action as indicated.