| Recurring |
one_organization |
(a) The software failure incident has happened again at one_organization:
The Department of Veterans Affairs has experienced software failure incidents in the past related to modernizing their electronic health record system. The current overhaul of the health record system using new software from Cerner Corporation has faced significant challenges, including issues with training, usability, and unexpected costs [116345].
(b) The software failure incident has happened again at multiple_organization:
There is no specific mention in the provided article about similar software failure incidents happening at other organizations. |
| Phase (Design/Operation) |
design, operation |
(a) The software failure incident in the Department of Veterans Affairs' electronic health record system overhaul can be attributed to design-related factors introduced during the system development phase. The incident was a result of underestimating costs, flawed and confusing training programs, rushed implementation, and a lack of consultation with frontline health care workers during the development and rollout of the new system [116345].
(b) Additionally, the software failure incident can also be linked to operation-related factors introduced during the operation phase of the system. Issues such as inadequate training, lack of access to practice software, inability of trainers to answer practical use questions, and confusion leading to errors in drug prescriptions and delays in medication delivery highlight operational failures in the system's implementation and usage [116345]. |
| Boundary (Internal/External) |
within_system, outside_system |
(a) within_system: The software failure incident at the Department of Veterans Affairs was primarily due to factors originating from within the system. The failure was attributed to issues such as underestimation of costs by billions, flawed and confusing training programs for hospital staff, rushed and inadequate training, cumbersome new system leading to decreased productivity, unexpected extra costs, and problems with the software itself causing confusion and errors in patient care [116345].
(b) outside_system: While there were challenges within the system contributing to the software failure incident, there were also external factors that played a role. For example, the no-bid contract awarded by the Trump administration to the company for the overhaul, lack of consultation with frontline health care workers, inadequate access to practice software, and trainers' inability to answer practical use scenario questions were external factors that impacted the rollout of the new health record software [116345]. |
| Nature (Human/Non-human) |
non-human_actions |
(a) The software failure incident in the Department of Veterans Affairs' electronic health record system overhaul was primarily due to non-human actions. The failure was attributed to factors such as underestimation of costs by the contractor, flawed and confusing training programs, unexpected extra costs for new equipment, and the complexity of the new software causing decreased productivity [116345]. These issues were not directly caused by human actions but rather by systemic and technical challenges in the implementation process. |
| Dimension (Hardware/Software) |
software |
(a) The software failure incident reported in Article 116345 is primarily related to software issues rather than hardware. The failure stemmed from the flawed and confusing training program created by the company awarded the contract for the overhaul. Employees found the training rushed and inadequate, leading to a decrease in productivity and a feeling of failure among staff members. Additionally, the new system was described as cumbersome, causing tasks that were previously simple to become complex [116345].
(b) The software failure incident in Article 116345 is directly related to software issues. The new health record software implemented by the Department of Veterans Affairs was reported to be flawed and confusing, leading to a decrease in productivity, failed proficiency tests among employees, and an overall negative impact on the efficiency and speed of care in the veterans' health system. The software upgrade also resulted in unexpected extra costs due to the need for new equipment to run the new software [116345]. |
| Objective (Malicious/Non-malicious) |
non-malicious |
(a) The software failure incident described in the articles is non-malicious. The failure was primarily due to factors such as underestimation of costs, flawed training programs, rushed implementation, inadequate preparation, and lack of consultation with frontline health care workers [116345]. These factors led to a situation where the new health record software did not function as intended, causing a decrease in productivity, confusion among staff, and risks to patient care. There is no indication in the articles that the failure was a result of malicious intent to harm the system. |
| Intent (Poor/Accidental Decisions) |
poor_decisions, accidental_decisions |
(a) The software failure incident at the Department of Veterans Affairs was primarily due to poor decisions made during the overhaul of the electronic health record system. The decision to award a no-bid contract to a company that underestimated costs by billions, the flawed and confusing training program created by the company, and the lack of consultation with frontline health care workers all contributed to the failure [116345]. Additionally, the decision to remove outliers and manipulate data to make the official results look better also reflects poor decision-making [116345].
(b) The software failure incident also involved accidental decisions or unintended consequences. For example, employees were not given access to software they could practice on, trainers were unable to answer practical use scenario questions, and the system was so confusing that it led to errors like veterans receiving the wrong drugs and nurses breaking down in tears [116345]. These unintended consequences contributed to the failure of the software implementation. |
| Capability (Incompetence/Accidental) |
development_incompetence, accidental |
(a) The software failure incident in the Department of Veterans Affairs' new health record system can be attributed to development incompetence. The company awarded a no-bid contract for the overhaul underestimated costs by billions, and the training program for hospital staff was described as flawed and confusing, leading to a high failure rate in proficiency tests [116345].
(b) Additionally, the software failure incident can also be linked to accidental factors, such as the lack of consultation with frontline health care workers, employees not being given access to software for practice, and trainers being unable to answer practical use scenario questions effectively [116345]. |
| Duration |
permanent |
(a) The software failure incident in this case appears to be more of a permanent nature. The Department of Veterans Affairs initiated a major overhaul of its electronic health record system, which was intended to be a long-term solution to modernize their outdated system. However, the rollout of the new software was plagued with issues from the start, including underestimation of costs, flawed training programs, decreased productivity, and confusion among staff members. These problems seem deeply rooted in the implementation and design of the new system, indicating a more permanent failure rather than a temporary setback [116345]. |
| Behaviour |
crash, omission, timing, value, byzantine, other |
(a) crash: The software failure incident in the Department of Veterans Affairs' new health record system at the Mann-Grandstaff V.A. Medical Center in Spokane, Washington, led to a significant decrease in productivity by about one-third, indicating a crash in the system's performance [116345].
(b) omission: Employees at the Mann-Grandstaff V.A. Medical Center complained that tasks that were simple before became complex after the software upgrade, suggesting an omission in the system's performance [116345].
(c) timing: The software failure incident resulted in delays and errors in medication prescriptions, causing veterans to receive the wrong drugs and suffer withdrawal due to delayed prescriptions, indicating a timing issue in the system's performance [116345].
(d) value: There were reports of a V.A. doctor ordering a veteran two medications, but the veteran received 15 erroneous medications, highlighting a value-related failure in the system's performance [116345].
(e) byzantine: The training program for hospital staff on the new health record system was described as "flawed and confusing," with many employees considering it "an utter waste of time." Additionally, employees who completed the training still faced difficulties in using the new system, indicating inconsistent responses and interactions, resembling a byzantine behavior in the system [116345].
(f) other: The software failure incident also involved unexpected extra costs due to the need for additional equipment to run the new software, which could be categorized as an economic impact or financial strain resulting from the failure incident [116345]. |