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Patient safety issues with VA Cerner EHR caused harm to veterans, federal watchdog says

A new patient medical records system at a Spokane Veterans Affairs hospital in the US has caused nearly 150 cases of patient harm, according to a federal watchdog agency.

An inspection by the VA Office of the Inspector General (OIG) found that a new Cerner electronic health record (EHR) system, now owned by Oracle, failed to deliver more than 11,000 orders for specialty care, lab work and other services at Mann-Grandstaff VA Medical Center, the first VA facility to roll out the new technology.

The OIG review found that the new EHR sent thousands of orders for medical care to an undetectable location, or unknown queue, instead of the intended care or service location, effectively causing the orders to disappear without letting clinicians know they weren't delivered.

The intent of the unknown queue is to capture orders entered by providers that the new EHR cannot deliver to the intended location because the orders were not recognized as a “match” by the system, according to the VA watchdog.

From facility go-live in October 2020 through June 2021, the new EHR failed to deliver more than 11,000 orders for requested clinical services.

Those lost orders, often called referrals, resulted in delayed care and what a VA patient safety team classified as dozens of cases of "moderate harm" and one case of "major harm."

The clinical reviewers conducted 1,286 facility event assessments and identified and classified 149 adverse events for patients.

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Source: Fierce Healthcare, 20 July 2022


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