A flaw in a Cerner electronic health record (EHR) deployed at the Mann-Grandstaff VA Medical Center in Spokane, Washington included an “unknown queue” that resulted in thousands of patient care issues, according to Deputy Inspector General David Case in the Office Of Inspector General, Department Of Veterans Affairs.
“Over the past year, the OIG has been examining how the new EHR has been affecting users and patients. Most recently, the OIG determined that the new EHR system directed thousands of medical orders to an “unknown queue” that was not evident to the clinical and administrative staff responsible for addressing them. The OIG also found that the Veterans Health Administration (VHA) determined the lack of knowledge and maintenance of the unknown queue created significant risk and caused harm to nearly 150 veterans. As recently as July 2022, hundreds of orders remained in the unknown queue across VA sites implementing the new system. The Deputy Secretary’s response to the unknown queue report asserted that issues with the unknown queue have been resolved. However, VA stated that mitigation work continues, and Oracle Cerner leadership confirmed in Congressional testimony last week that further technology updates are required,” Case said.
“Looking back to October 24, 2020, through May 8, 2022, VHA identified 1,134 total patient safety events related to the new EHR. VHA’s analysis identified one catastrophic patient harm (death or major permanent loss of function) and two major patient harm cases (permanent lessening of bodily functioning), one of which was related to the unknown queue,” he added later.
For more information, view the full statement.
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