OIG Report on VHA Finds 'Multiple Events of Patient Harm' in Oracle Cerner EHR

The VA Office of Inspector General cites nearly 150 adverse events connected to a routing glitch, and says "insufficient mitigations" and "continued risk to patient safety" leave it with big concerns about the so-called "unknown queue." The final version of the VA Office of Inspector General's report on the electronic health record deployment at Mann-Grandstaff VA Medical Center was published on July 14. As was noted when a draft of the report was released this past month, the VA watchdog undertook a rigorous review of the new Veterans Health Administration EHR, and found 149 instances of patient harm (mostly characterized as "minor," but with a couple significant adverse events detailed by the IG) related to an element of the Oracle Cerner EHR known as the "unknown queue" – a glitch where the tool to manage orders with incomplete routing information failed to alert VA clinicians when those notes didn't arrive where they were needed. "The new EHR’s unknown queue represented an element that ultimately led to thousands of orders for medical care not being delivered to the requested service, placed patients at risk for incomplete care, and caused multiple events of patient harm," said the OIG report.

Upon review, the OIG discovered that the EHR "sent thousands of orders for medical care to an undetectable location, or unknown queue, instead of the intended care or service location (e.g., specialty care, laboratory, diagnostic imaging)." The report notes that "every version of Oracle Cerner’s EHR has an option to activate the unknown queue." "On May 16, 2022, the OIG used the new EHR to generate a report of the orders in the unknown queue for VHA sites and found 206 orders," it continues. In one of them, a provider "entered a follow-up psychiatric care order for a homeless patient identified as at risk for suicide," according to the OIG report. Despite some of the preventative steps laid out in the report, the OIG emphasized that, "based on the multiple events of patient harm, insufficient mitigations that burden VHA staff, and continued risk to patient safety," it "remains concerned with the management of the new EHR’s unknown queue." "Not only were 149 veterans in Eastern Washington harmed by the broken electronic health record system, VA and Oracle Cerner leadership downplayed the severity of the issue of the unknown queue, failed to adequately train providers on site and manipulated data to support a non-factual narrative about general system training and user proficiency."