| Recurring |
one_organization, multiple_organization |
(a) The software failure incident has happened again at one_organization:
The software failure incident related to the modernization of veterans' medical records occurred at the Mann-Grandstaff VA Medical Center in Spokane, Washington. The deployment of the new electronic health record system built by Cerner led to serious deficiencies and failures, increasing risks to patient safety and making it difficult for clinicians to provide quality healthcare [125464].
(b) The software failure incident has happened again at multiple_organization:
The reports on the software overhaul at the Mann-Grandstaff VA Medical Center in Spokane, Washington, highlighted systemic issues with the implementation of the new electronic health record system. These issues included training problems, scheduling challenges, cost estimate discrepancies, and access to care issues. The problematic rollout of the project was not limited to one organization but extended to various hospitals and clinics in the Pacific Northwest and elsewhere [125464]. |
| Phase (Design/Operation) |
design, operation |
(a) The software failure incident in the Department of Veterans Affairs' modernization of veterans' medical records system was primarily due to design-related issues introduced during the system development phase. The Inspector General's reports highlighted serious deficiencies and failures in the implementation of the new electronic health record system at the Mann-Grandstaff VA Medical Center, which increased risks to patient safety and made it more difficult for clinicians to provide quality healthcare [125464].
(b) Additionally, the software failure incident also involved operation-related issues caused by the operation or misuse of the system. For example, medical staff struggled to use the system, leading to plummeting productivity. Issues such as long appointment scheduling times, inability to log in to the secure website, unanswered troubleshooting requests, medication errors, and missing suicide prevention tools all point to operational challenges that affected patient care [125464]. |
| Boundary (Internal/External) |
within_system |
(a) within_system: The software failure incident at the Department of Veterans Affairs' medical records modernization project was primarily due to internal factors within the system. The failure was attributed to serious deficiencies and failures in the implementation of the new electronic health record system at the Mann-Grandstaff VA Medical Center, leading to increased risks to patient safety and making it difficult for clinicians to provide quality healthcare [125464].
(b) outside_system: The articles do not provide specific information about contributing factors originating from outside the system that led to the software failure incident. |
| Nature (Human/Non-human) |
non-human_actions, human_actions |
(a) The software failure incident in the Department of Veterans Affairs' modernization of veterans' medical records was primarily due to non-human actions, specifically technical and management challenges related to the software deployment by technology giant Cerner. Issues included medication errors, failures in safeguarding patients at high risk of suicide, difficulties in scheduling medical appointments, inability to access personal health information, bad computer links for telehealth appointments, unprocessed outpatient orders for drugs, inaccurate transfer of patient information, and failure to activate patient records for high-risk patients. These challenges led to a significant decrease in productivity and posed serious risks to patient safety [125464].
(b) Human actions also played a role in the software failure incident, as highlighted by the reports from the Department of Veterans Affairs' internal watchdog. The reports identified serious deficiencies and failures in the implementation of the new electronic health record system at the Mann-Grandstaff VA Medical Center. Issues such as training, scheduling, cost estimates, access to care, and VA's readiness to roll out the project were raised, indicating that human actions, decisions, and oversight contributed to the problematic rollout of the software [125464]. |
| Dimension (Hardware/Software) |
software |
(a) The software failure incident reported in the articles is primarily attributed to software-related contributing factors rather than hardware-related issues. The failure was due to serious deficiencies and failures in the implementation of the new electronic health record system at the Mann-Grandstaff VA Medical Center, leading to increased risks to patient safety and making it more difficult for clinicians to provide quality healthcare [125464].
The issues mentioned in the articles include problems with the software deployment such as medical staff struggling to use the system, difficulties in scheduling medical appointments, inability for veterans to log in to the secure website, bad computer links for telehealth appointments, unanswered troubleshooting requests, inaccurate transfer of patient information, medication errors, unprocessed drug orders, missing suicide prevention tools, and patient records not activating as intended [125464].
These issues highlight software-related failures in the implementation of the new electronic health record system, indicating that the root causes of the failure incidents originate in the software rather than hardware components. |
| Objective (Malicious/Non-malicious) |
non-malicious |
(a) The software failure incident described in the articles does not appear to be malicious. The failure was primarily attributed to non-malicious factors such as technical challenges, management issues, lack of proper training, and difficulties in transitioning from the old system to the new one. There is no indication in the articles that the failure was caused by intentional actions to harm the system or its users [125464]. |
| Intent (Poor/Accidental Decisions) |
poor_decisions |
(a) The software failure incident at the Department of Veterans Affairs' modernization of veterans' medical records was primarily due to poor decisions. The failure was a result of serious deficiencies and failures in the implementation of the new electronic health record system, which increased risks to patient safety and made it more difficult for clinicians to provide quality healthcare [125464]. The reports highlighted issues such as medication errors, failures in safeguarding patients at high risk of suicide, difficulties in scheduling medical appointments, inaccurate transfer of patient information, unprocessed drug orders, and missing suicide prevention tools. These problems stemmed from decisions made during the deployment of the software overhaul by technology giant Cerner, leading to a crisis that affected productivity and patient care. |
| Capability (Incompetence/Accidental) |
development_incompetence, accidental |
(a) The software failure incident reported in the articles seems to be primarily due to development incompetence. The reports highlighted serious deficiencies and failures in the implementation of the new electronic health record system at the Mann-Grandstaff VA Medical Center, which increased risks to patient safety and made it difficult for clinicians to provide quality healthcare [125464]. Issues such as medication errors, failures in safeguarding patients at high risk of suicide, difficulties in scheduling medical appointments, unresponsiveness to troubleshooting requests, inaccurate transfer of patient information, and activation failures for patients flagged in the legacy system all point towards failures in the development and implementation process.
(b) Additionally, there are indications of accidental factors contributing to the software failure incident. For example, the reports mentioned that the majority of issues were still outstanding, and investigators were unable to determine whether any serious medical issues or deaths resulted from the mishaps [125464]. The blackout that disrupted multiple clinical operations for roughly 20 hours in Spokane was also mentioned as an accidental glitch with data migration issues, further highlighting accidental factors contributing to the incident. |
| Duration |
temporary |
(a) The software failure incident described in the articles appears to be temporary. The incident involved a disastrous deployment of a new electronic health record system at the Mann-Grandstaff VA Medical Center, leading to serious deficiencies and failures in the implementation of the system. Issues such as medication errors, failures in safeguarding patients at high risk of suicide, difficulties in scheduling medical appointments, inability to access personal health information, and unprocessed medication orders were reported. The system also failed to activate patient records for those at high risk, impacting patient safety and clinical care [125464].
The incident caused a crisis where productivity plummeted, medical staff struggled to use the system, and many veterans were left to fend for themselves. The reports highlighted unresolved issues and ongoing problems with the deployment of the new electronic health record system, indicating that the failure was not permanent but rather a result of specific circumstances surrounding the deployment process. The VA acknowledged the rocky start and continuing problems but mentioned making substantial changes and improvements, including additional training for medical staff and plans to address outstanding issues by mid-May [125464]. |
| Behaviour |
crash, omission, timing, value, byzantine, other |
(a) crash: The software failure incident in the article can be categorized as a crash due to the system losing state and not performing its intended functions. The deployment of the new electronic health record system at the Mann-Grandstaff VA Medical Center led to a crisis where productivity plummeted as medical staff struggled to use the system, leaving many veterans to fend for themselves. Medical appointments took months to schedule, veterans could not log in to the secure website, and many tickets from medical staff asking for troubleshooting went unanswered, among other issues [125464].
(b) omission: The software failure incident also involved omission, where the system omitted to perform its intended functions at instances. For example, patient records that should have shown patients at high risk for suicide and disruptive behavior failed to activate for flagged patients in the legacy system. This omission was particularly alarming given that suicide prevention is one of VA's top clinical priorities [125464].
(c) timing: The timing of the software failure incident can be considered a factor as well. While the system was intended to perform certain functions, it did so too late or too early, leading to delays in medical appointments, issues with medication lists, unprocessed drug orders, and other timing-related problems that affected patient care [125464].
(d) value: The software failure incident also involved failures related to the value, where the system performed its intended functions incorrectly. For instance, physicians could not tell if patients' medications were discontinued or expired, medications sent by mail order had confusing or missing instructions, and registered nurses were able to order medications without proper reviews and approvals by doctors [125464].
(e) byzantine: The software failure incident exhibited characteristics of a byzantine failure as well. The system behaved erroneously with inconsistent responses and interactions, leading to a range of issues such as inaccurate transfer of patient information, bad computer links for telehealth appointments, and the inability of medical staff to access necessary suicide-prevention risk assessment and reporting tools [125464].
(f) other: In addition to the above behaviors, the software failure incident in the article can be categorized under "other" as well. This includes issues related to training, scheduling, cost estimates, access to care, and VA's readiness to roll out the project. The reports identified unresolved issues that lacked a timeline or plan for mitigation, indicating a broader range of challenges beyond the specific behaviors mentioned above [125464]. |