how automated healthcare fails, how you'd know, and what to do at each tier — every claim sourced, reviewed continuously
After go-live, the new EHR routed more than 11,000 clinical orders to a hidden queue instead of the intended service, without telling the ordering clinician; VHA identified 149 adverse events.
TierThe automation stayed up and kept producing output that was wrong or went unchecked; there was no outage to fall back from. How tiers are assigned.
The new EHR let providers pick service locations that the system could not match; unmatched orders went to an 'unknown queue' rather than to specialty care, lab or imaging, and the provider received no alert. From go-live in October 2020 to June 2021 more than 11,000 orders were not delivered. The first trouble ticket about lost orders was placed on 28 October 2020, four days after go-live; the OIG found no evidence that the vendor gave VA actionable information about the queue beforehand. VHA's clinical review of 1,286 event assessments classified 149 adverse events (2 major, 52 moderate, 95 minor). Mitigation relied on staff manually monitoring and re-entering queued orders; 206 orders were still in the queue across VHA sites on 16 May 2022.[1]
149 adverse events classified by VHA: 2 major harm, 52 moderate, 95 minor.
All incidents · Connectivity & data · Human handoff
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