The death of four veterans and an overall figure of six incidences of catastrophic harm including were reported by the Department of Veterans Affairs (VA) to the Senate committee staff. These occurrences have been found to be correlated to patient safety problems with the Oracle Cerner VA EHR Modernization (EHRM) program, designed to improve veteran’s patient outcomes.
Of these veterans, no cause of death was released due to confidentiality, however, it is likely that previously reported safety issues with the program may have been the determining factor in these fatalities. Frequent issues noted by veteran’s include:
- insufficient or incorrect prescription processing
- medication management of veterans engaged in care
- clinical referral issues
- incorrectly identifying patients at risk of suicide
One of the four deaths occurred at Spokane’s Mann-Grandstaff VA Medical Center, and the other three occurred as patients in the VA Central Ohio Healthcare System, which has been an active operator for under twelve months. The two veterans that experienced non-fatal catastrophic harm reside in the Inland Northwest. The VA recently sent letters to over seventy thousand veterans informing them that issues with the Oracle Cerner system are likely responsible for disruptions to their individual medical treatments. There was a clear awareness of the issues involved in the program and it was stated last year that the program wouldn’t be launched while issues remained prominent. VA administrators decided to roll out the system regardless of the evident issues, in both southern Oregon and Ohio prior to 2023, in addition to Walla Walla’s VA hospital following their assurance that deployment wouldn’t take place until issues were amended. The VA gave Congress a report outlining 14 safety issues with the system, an evaluation that began in October. An Office of Inspector General (OIG) report was released almost two years ago illustrating that harm had been done to more than one hundred veterans, yet the VA proceeded and have now potentially caused fatal harm to veterans that entrusted them with their healthcare journey. The chair of the Senate Appropriations Committee has issued statements on the dangers to patient safety brought on by system’s fault, labelling them as unacceptable and making it clear that the funding he currently controls will be withheld while the issues remain unresolved. In response to the fatalities, the VA has also proposed a renegotiation of the five-year option period for Oracle Cerner’s Millennium platform, with the introduction of new penalty measures for problems that arise , as well as further discussion of the current EHR patient safety issues that has already caused significant harm.
Dr. Neil Evans, the chief officer for the Office of Connected Care in the VHA, commented on the harm caused to veterans, stating : “We take every episode where there is harm and we evaluate it carefully to try and understand why. It’s never good, we are never satisfied when it happens.”
