Incident: Malpractice and Mismanagement at VA Medical Centers Led to Veteran Deaths

Published Date: 2014-06-24

Postmortem Analysis
Timeline 1. The software failure incident happened in the past decade as per the article [27304]. 2. The article was published on 2014-06-24. 3. Estimation: The incident likely occurred sometime between 2004-2014.
System The software failure incident reported in the news article does not directly mention any specific software systems, components, models, or versions that failed. The focus of the article is on malpractice, lack of care, budget mismanagement, fraudulent scheduling practices, and systemic issues affecting VA hospitals and clinics. Therefore, the specific software systems or components that failed are unknown based on the provided information.
Responsible Organization 1. Lack of proper budgeting and management at the Department of Veterans Affairs (VA) medical centers [27304] 2. Fraudulent scheduling practices and budget mismanagement within the VA [27304] 3. Insufficient oversight and lack of accountability within the VA [27304]
Impacted Organization 1. Veterans Affairs medical centers [27304]
Software Causes 1. Lack of proper budgeting and management of the VA's budget, leading to mismanagement and compromising veterans' access to medical care [27304] 2. Fraudulent scheduling practices and insufficient oversight within VA hospitals and clinics, contributing to delayed care and patient deaths [27304] 3. Allegations of administrators altering appointment data to make patient wait times appear shorter, potentially involving manipulation of software systems [27304]
Non-software Causes 1. Lack of care and malpractice at VA medical centers over the last decade [27304] 2. Fraudulent scheduling practices and budget mismanagement within the Department of Veterans Affairs [27304] 3. Insufficient oversight and lack of accountability within the VA system [27304] 4. Poor management and budget misallocation within the VA, leading to compromised access to medical care for veterans [27304] 5. Financial incentives for managers to hide delays in patient care [27304] 6. Crimes committed by VA staff, including drug dealing, theft, and sexual abuse of patients [27304]
Impacts 1. The software failure incident led to fraudulent scheduling practices at VA medical centers, resulting in delayed care and ultimately the deaths of veterans [27304]. 2. The incident caused budget mismanagement and insufficient oversight at the VA, leading to systemic issues affecting hospitals and clinics throughout the U.S. [27304]. 3. The failure of proper management and budget handling due to the software incident resulted in more than 1,000 veteran deaths over the past decade [27304]. 4. The software failure incident allowed for the allocation of funds to non-health-related projects instead of improving veterans' access to medical care [27304]. 5. The incident contributed to a controversial performance bonus system that incentivized managers to hide patient wait times, compromising the quality of care provided by the VA [27304].
Preventions 1. Proper budgeting and management: The software failure incident, which led to more than 1,000 veteran deaths due to malpractice or lack of care at VA medical centers, could have been prevented if the VA's budget had been properly handled and the right management practices were in place [27304]. 2. Improved oversight and accountability: Insufficient oversight and lack of accountability within the VA system contributed to the systemic issues that led to patient deaths. Strengthening oversight mechanisms and ensuring accountability could have prevented the software failure incident [27304]. 3. Timely and accurate data management: The manipulation of appointment data and records at VA medical centers, such as changing records of dead veterans to hide wait times, was a critical factor in the failure incident. Implementing robust data management practices to ensure the accuracy and integrity of patient records could have prevented the incident [27304].
Fixes 1. Proper budgeting and management of the VA's budget could have prevented many of the deaths linked to malpractice and lack of care at VA medical centers [27304]. 2. Implementing better oversight and accountability measures within the VA system to address systemic issues affecting VA hospitals and clinics throughout the U.S. could help prevent future incidents [27304]. 3. Addressing fraudulent scheduling practices and ensuring timely access to healthcare services for veterans could mitigate the risks associated with delayed care [27304]. 4. Enhancing the VA's IT systems to accurately track and manage patient appointments and healthcare data could improve the overall efficiency and effectiveness of healthcare delivery within the VA system [27304].
References 1. Government investigations 2. Media reports 3. VA's inspector general 4. U.S. Office of Special Counsel 5. VA medical review agency 6. VA officials 7. CNN investigation 8. VA assistant secretary for human resources and administration 9. VA's Office of Inspector General 10. Former VA Regional Director Michael Moreland 11. Acting VA Secretary Sloan Gibson 12. Sen. Tom Coburn's office 13. Whistle-blower 14. Former VA staffer at the Tampa, Florida, VA 15. VA facility personnel 16. Veterans 17. Patients [27304]

Software Taxonomy of Faults

Category Option Rationale
Recurring unknown The articles do not mention any specific software failure incident happening again at a particular organization or across multiple organizations. Therefore, the information related to the software failure incident happening again at one organization or multiple organizations is unknown.
Phase (Design/Operation) design, operation (a) The software failure incident related to the design phase is evident in the article through the mention of fraudulent scheduling practices, budget mismanagement, insufficient oversight, and lack of accountability within the Department of Veterans Affairs medical centers [27304]. These issues point to failures introduced during the system development or updates, which have led to systemic issues affecting VA hospitals and clinics, ultimately resulting in patient deaths and controversies plaguing the VA. (b) The software failure incident related to the operation phase is highlighted in the article by instances of delayed care leading to patient deaths, veterans waiting excessive periods for VA health care, and allegations of administrators altering appointment data to make patient wait times appear shorter [27304]. These operational failures, including delays in care and manipulation of data, have directly impacted the health and well-being of veterans accessing medical care through the VA system.
Boundary (Internal/External) within_system (a) within_system: The software failure incident related to the VA medical centers can be attributed to factors originating from within the system. The failure was due to fraudulent scheduling practices, budget mismanagement, insufficient oversight, lack of accountability, poor management, and a controversial performance bonus system that incentivized managers to hide patient care delays ([27304]). These internal factors within the VA system led to issues such as delayed care, malpractice, and even deaths of veterans.
Nature (Human/Non-human) human_actions (a) The software failure incident occurring due to non-human actions: - The articles do not mention any software failure incident specifically attributed to non-human actions. (b) The software failure incident occurring due to human actions: - The articles highlight various instances of malpractice, fraudulent scheduling practices, budget mismanagement, insufficient oversight, lack of accountability, and crimes committed by VA staff that have contributed to the systemic issues affecting VA hospitals and clinics [27304]. - Human actions such as improper budgeting, mismanagement, and lack of accountability are mentioned as factors that could have prevented many deaths at VA medical centers [27304]. - The report also mentions how financial incentives for managers led to the hiding of patient wait times, contributing to the controversy surrounding the VA's performance bonus system [27304]. - Instances of crimes committed by VA staff, including drug dealing, theft, and sexual abuse of patients, are highlighted in the articles [27304]. - The articles mention how records of dead veterans were changed at the Phoenix VA hospital to hide the number of veterans who died while waiting for care, indicating human actions to manipulate data [27304].
Dimension (Hardware/Software) unknown (a) The articles do not specifically mention any software failure incident occurring due to hardware issues. Therefore, there is no information available regarding a software failure incident related to hardware in the provided articles. (b) The articles do not explicitly mention a software failure incident originating from software issues. However, the overall context of the articles focuses on systemic issues within the Department of Veterans Affairs, including fraudulent scheduling practices, budget mismanagement, insufficient oversight, and lack of accountability that have led to patient deaths and controversies. These issues are more related to organizational and management failures rather than direct software failures.
Objective (Malicious/Non-malicious) malicious, non-malicious (a) The software failure incident related to malicious intent: - The articles mention crimes committed by VA staff, including drug dealing, theft, and sexual abuse of patients [27304]. - A former staffer at the Tampa, Florida, VA was sentenced to six years in federal prison for trading veterans' personal information for crack cocaine [27304]. - A CNN investigation uncovered a scheme at the Phoenix VA hospital where records of dead veterans were changed to hide how many died while waiting for care [27304]. (b) The software failure incident related to non-malicious factors: - The report highlights fraudulent scheduling practices, budget mismanagement, insufficient oversight, and lack of accountability as systemic issues affecting VA hospitals and clinics, leading to patient deaths [27304]. - The VA's budget mismanagement, improper handling, and poor management are mentioned as factors contributing to the deaths of veterans [27304]. - The VA's allocation of funds to non-health-related projects, excessive expenditures, and scheduling delays in construction projects are highlighted as non-malicious contributing factors to the failures [27304].
Intent (Poor/Accidental Decisions) unknown The articles do not provide specific information about a software failure incident related to poor decisions or accidental decisions.
Capability (Incompetence/Accidental) accidental (a) The articles do not mention any specific software failure incident related to development incompetence. (b) The articles highlight incidents where VA staff committed crimes such as drug dealing, theft, and sexual abuse of patients [27304]. Additionally, a CNN investigation uncovered a scheme at the Phoenix VA hospital where records of dead veterans were changed to hide how many died while waiting for care [27304]. These incidents could be categorized as software failure incidents occurring due to accidental factors introduced by individuals within the organization.
Duration unknown The articles do not provide information specifically related to a software failure incident in terms of duration being permanent or temporary.
Behaviour omission, timing, value, other (a) crash: The articles do not specifically mention a software crash as the primary cause of the failure incidents reported. (b) omission: The articles highlight instances of delayed care and fraudulent scheduling practices within the VA medical centers, which can be considered as omissions in performing the intended functions of providing timely healthcare to veterans [27304]. (c) timing: The articles discuss how veterans had to wait excessive periods for VA health care, leading to some veterans dying in the process. This indicates a timing failure where the system performed its intended functions, but too late to prevent negative outcomes [27304]. (d) value: The articles mention cases where patients died due to delayed care, malpractice, and lack of proper management within the VA medical centers. These instances point to a failure in the system performing its intended functions incorrectly, resulting in harm to the patients [27304]. (e) byzantine: The articles do not explicitly describe a byzantine behavior of the software system in the reported failure incidents. (f) other: The articles also mention budget mismanagement, insufficient oversight, lack of accountability, and allocation of funds to non-health-related projects within the VA, which can be considered as additional factors contributing to the failure incidents reported [27304].

IoT System Layer

Layer Option Rationale
Perception None None
Communication None None
Application None None

Other Details

Category Option Rationale
Consequence death, harm, delay (a) death: People lost their lives due to the software failure - The article mentions that more than 1,000 veterans may have died in the last decade due to malpractice or lack of care from Department of Veterans Affairs medical centers [27304]. - The report titled "Friendly Fire: Death, Delay, and Dismay at the VA" shows that many patient deaths have been linked to systemic issues affecting VA hospitals and clinics throughout the U.S. [27304]. - It is noted that 23 patients have died because of delayed care in recent years, but the actual number of patient deaths linked to systemic issues is much higher [27304]. - The article also highlights an outbreak of Legionnaires’ disease at the Pittsburgh VA, where six veterans died in 2011 and 2012 due to failed infection prevention policies [27304]. (b) harm: People were physically harmed due to the software failure - The article mentions crimes committed by VA staff, including drug dealing, theft, and sexual abuse of patients dating back many years [27304]. - A former staffer at the Tampa, Florida, VA was sentenced to six years in federal prison for trading veterans’ personal information for crack cocaine [27304]. (e) delay: People had to postpone an activity due to the software failure - Veterans had to wait excessive periods for VA health care, causing some to die in the process [27304]. - Records of dead veterans were changed at the Phoenix VA hospital to hide how many died while waiting for care, indicating delays in providing necessary medical attention [27304]. - The VA's inspector general is investigating 69 medical centers for allegations that administrators altered appointment data to make patient wait times appear to be shorter [27304].
Domain health, government The software failure incident reported in the articles is related to the **health** industry. The failed system was intended to support the operations of the Department of Veterans Affairs (VA) medical centers, which provide healthcare services to veterans. The incident involved malpractice, lack of care, fraudulent scheduling practices, budget mismanagement, insufficient oversight, and lack of accountability within the VA healthcare system, leading to patient deaths and systemic issues affecting VA hospitals and clinics throughout the U.S. [Article 27304]

Sources

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