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A number of veterans were harmed because information from the Department of Veterans Affairs electronic health record (EHR) system sent information to an unknown location. The VA inspector general’s office (OIG) found that the error involved thousands of orders for medical care. The IG deemed the involved risk as a “major severity” that was “frequently occurring [and] very difficult to detect.”
The report also said that Oracle Cerner, the company that developed and manages the electronic records system, failed to notify VA of the problem and left the Veterans Health Administration (VHA) with the responsibility of handing it internally.
“Beginning in June 2021, VHA staff spent substantial hours to complete clinical reviews to access patient risk and harm related to the unknown queue and found that the new HER’s delivery of orders to the unknown queue caused 149 patients harm,” the IG report stated.
Later last year, VHA staff informed the VA manager in charge of EHR modernization of their safety concerns and identified specific areas in which patients were harmed. Now, each VA facility is being required to step up monitoring efforts and address issues with the unknown queue.
Nevertheless, the IG reported finding more than 200 orders in that queue as of this past May.
“The OIG has concerns with the effectiveness of Cerner’s plan to mitigate the safety risk,” the report stated.
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