Deficiencies after the New Electronic Health Record Go-Live at the Mann-Grandstaff VA Medical Center in Spokane, WA. | PSNet

Provide Feedback |

Submit a Case

Register

Book/Report

Deficiencies after the New Electronic Health Record Go-Live at the Mann-Grandstaff VA Medical Center in Spokane, WA.

March 30, 2022

Washington, DC: VA Office of Inspector General; March 17, 2022.

Electronic health record (EHR) implementation failures cause major disruptions to care delivery that can result in inefficiencies, misinformation, and unsafe care. This three-part investigation examines the impact of the new United States Veterans Affairs EHR system problems on medication management, care coordination, and problem reporting and resolution at one facility.

Part I: OIG Report no. 21-00656-110

Part II: OIG Report no. 21-00781-109

Part III: OIG Report no. 21-00781-108

Related news article

Related Resources From the Same Author(s)

Comprehensive Healthcare Inspection Summary Report: Evaluation of Mental Health in Veterans Health Administration Facilities, Fiscal Year 2020.

March 16, 2022

Deficiencies in Emergent and Outpatient Care of a Patient with Alcohol Use Disorder at the Richard L. Roudebush VA Medical Center in Indianapolis, Indiana.

April 19, 2023

Comprehensive Healthcare Inspection Summary Report: Evaluation of Care Coordination in Veterans Health Administration Facilities, Fiscal Year 2021.

October 12, 2022

The New Electronic Health Record’s Unknown Queue Caused Multiple Events of Patient Harm.

July 27, 2022

Multiple Failures in Test Results Follow-up for a Patient Diagnosed with Prostate Cancer at the Hampton VA Medical Center in Virginia.

July 13, 2022

Critical Deficiencies at the Washington DC VA Medical Center.

March 21, 2018

Inadequate Outpatient Mental Health Triage and Care of a Patient at the Chico Community-Based Outpatient Clinic in California.

March 1, 2023

Deficiencies in the Community Care Network Credentialing Process of a Former VA Surgeon and Veterans Health Administration Oversight Failures.

January 24, 2024

Deficiencies in Quality Management Processes and Delays in the Communication of Test Results and Follow-Up Care at the Phoenix VA Health Care System in Arizona.

November 29, 2023

Quality of Care Concerns and the Facility Response Following a Medical Emergency at the VA Southern Nevada Health Care System in Las Vegas.

July 26, 2023

Healthcare Inspection: Evaluation of the Veterans Health Administration's National Consult Delay Review and Associated Fact Sheet.

January 14, 2015

Unexpected Death of a Patient During Treatment With Multiple Medications, Tomah VA Medical Center, Tomah, Wisconsin.

September 16, 2015

Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System.

September 10, 2014

Interim Report: Review of VHA's Patient Wait Times, Scheduling Practices, and Alleged Patient Deaths at the Phoenix Health Care System.

June 4, 2014

Evaluation of Registered Nurse Competency Processes in Veterans Health Administration Facilities.

June 13, 2012

Quality of Care in Cranial Implant Surgeries at James A. Haley VA Medical Center, Tampa, Florida.

April 26, 2006

Deficiencies in the Veterans Crisis Line Response to a Veteran Caller Who Died.

December 16, 2020

Opioids in Medicare Part D: Concerns About Extreme Use and Questionable Prescribing.

August 9, 2017

Incidence of Adverse Events in Indian Health Service Hospitals.

December 23, 2020

Adverse Events in Hospitals: Methods for Identifying Events.

March 17, 2010

Evaluation of Quality, Safety and Value in Veterans Health Administration Facilities, Fiscal 2021.

November 16, 2022

Adverse Events in Hospitals: A Quarter of Medicare Patients Experienced Harm in October 2018.

May 25, 2022

Long-Term Trends of Psychotropic Drug Use in Nursing Homes.

February 1, 2023

Corporate Responsibility and Health Care Quality: A Resource for Health Care Boards of Directors.

July 18, 2007

Inadequate Emergency Department Care and Physician Misconduct at the Washington DC VA Medical Center.

August 12, 2020

Deficiencies in Inpatient Mental Health Care Coordination and Processes Prior to a Patient's Death by Suicide, Harry S. Truman Memorial Veterans' Hospital in Columbia, Missouri.

February 10, 2021

Deficiencies in Emergency Preparedness for Veterans Health Administration Telemental Health Care at VA Clinic Locations Prior to the Pandemic.

July 14, 2021

Care and Oversight Deficiencies Related to Multiple Homicides at the Louis A. Johnson VA Medical Center in Clarksburg, West Virginia.

May 26, 2021

Deficiencies in Care, Care Coordination, and Facility Response to a Patient Who Died by Suicide, Memphis VA Medical Center in Tennessee.

September 30, 2020

Failures in Care Coordination and Reviewing a Patient's Death at the VA Salt Lake City Healthcare System in Utah.

August 25, 2021

Deficiencies in Emergency Department Care for a Patient Who Died by Suicide at the John Cochran Division of the VA St. Louis Health Care System in Missouri.

August 2, 2023

Adverse Events Toolkit: Medical Record Review Methodology.

July 26, 2023

Adverse Events Toolkit: Clinical Guidance for Identifying Harm

July 19, 2023

Deficient Care of a Patient Who Died by Suicide and Facility Leaders' Response at the Charlie Norwood VA Medical Center in Augusta, Georgia.

July 5, 2023

Patient Suicide on a Locked Mental Health Unit at the West Palm Beach VA Medical Center, Florida.

September 4, 2019

Medicare’s Oversight of Compounded Pharmaceuticals Used in Hospitals.

February 11, 2015

Adverse Events in Rehabilitation Hospitals: National Incidence Among Medicare Beneficiaries.

July 27, 2016

Adverse Events in Long-Term-Care Hospitals: National Incidence Among Medicare Beneficiaries.

January 9, 2019

Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries.

November 24, 2010

Adverse Events in Hospitals: Public Disclosure of Information About Events.

January 20, 2010

Adverse Events in Skilled Nursing Facilities: National Incidence Among Medicare Beneficiaries.

March 19, 2014

Healthcare Inspection—Emergency Department Patient Deaths: Memphis VAMC, Memphis, Tennessee.

November 13, 2013

Few Adverse Events in Hospitals Were Reported to State Adverse Event Reporting Systems.

August 1, 2012

Hospital Incident Reporting Systems Do Not Capture Most Patient Harm.

January 18, 2012

Adverse Events in Hospitals: Medicare's Responses to Alleged Serious Events.

November 16, 2011

Deficiencies in Care Coordination and Facility Response to a Patient Suicide at the Minneapolis VA Health Care System, Minnesota.

January 29, 2020

Adverse Events in Hospitals: Care Study of Incidence Among Medicare Beneficiaries in Two Selected Counties.

February 18, 2009

Adverse Events in Hospitals: State Reporting Systems.

January 14, 2009

Adverse Events in Hospitals: Overview of Key Issues.

January 14, 2009

Trends in Nursing Home Deficiencies and Complaints.

October 29, 2008

Physician-Owned Specialty Hospital's Ability to Manage Medical Emergencies.

January 23, 2008

The Food and Drug Administration's National Drug Code Directory.

September 6, 2006

Evaluation of Quality, Safety, and Value in Veterans Health Administration Facilities, FY 2020.

September 15, 2021

Home Health Agencies Failed To Report Over Half of Falls With Major Injury and Hospitalization Among Their Medicare Patients.

November 8, 2023

Medicare's Oversight of Ambulatory Surgery Centers Report.

October 23, 2019

Medicare Part D Beneficiaries at Serious Risk of Opioid Misuse or Overdose: A Closer Look.

May 20, 2020

Hospital Experiences Responding to the COVID-19 Pandemic: Results of a National Pulse Survey March 23-27, 2020.

April 22, 2020

Hospital Reporting of Deaths Related to Restraint and Seclusion.

September 27, 2006

Nursing Home Complaint Investigations.

September 20, 2006

Assessment of DoD Wounded Warrior Matters: Managing Risks of Multiple Medications.

March 5, 2014

Addressing Health Worker Burnout.

June 8, 2022

Electronic Health Record Modernization Caused Pharmacy-Related Patient Safety Issues Nationally and at the VA Central Ohio Healthcare System in Columbus.

April 10, 2024

Patient Safety Organizations: Hospital Participation, Value, and Challenges.

October 16, 2019

Care Deficiencies and Leaders' Inadequate Reviews of a Patient Who Died at the Lt. Col. Luke Weathers, Jr. VA Medical Center in Memphis, Tennessee.

January 31, 2024

Deficiencies in Facility Leaders' Response to Critical Surgical Events at the Michael E. DeBakey VA Medical Center in Houston, Texas.

October 25, 2023

VA Patient Safety Program: A Cultural Perspective at Four Medical Facilities.

January 4, 2006

Artificial Intelligence in Health Care: Benefits and Challenges of Machine Learning Technologies for Medical Diagnostics.

October 26, 2022

Cybersecurity is Patient Safety: Policy Options in the Health Care Sector.

December 14, 2022

Pathology Oversight Failures at the Veterans Health Care System of the Ozarks in Fayetteville, Arkansas VA.

June 16, 2021

Adverse Events.

November 8, 2023

Medical malpractice claims by members of the uniformed services.

July 7, 2021

Actions Needed to Improve Newly Enrolled Veterans' Access to Primary Care.

May 4, 2016

Electronic Health Record Programs: Participation Has Increased, but Action Needed to Achieve Goals, Including Improved Quality of Care.

March 19, 2014

Trends in Pregnancy-Related Deaths and Federal Efforts to Reduce Them.

April 29, 2020

Health-Care-Associated Infections in Hospitals: Leadership Needed from HHS to Prioritize Prevention Practices and Improve Data on these Infections.

April 30, 2008

COVID-19 in Nursing Homes: CMS Needs to Continue to Strengthen Oversight of Infection Prevention and Control.

October 12, 2022

National Action Plan for Adverse Drug Event Prevention.

September 24, 2014

Goals and Priorities for Health Care Organizations to Improve Safety Using Health IT. Revised Report.

June 29, 2016

Medication Management: Detailed Use Case.

July 4, 2007

Oversight Hearing on Recent Patient Safety Issues.

June 28, 2006

Department of Defense Health Care Quality.

January 10, 2007

Health IT Safety Center Roadmap.

July 29, 2015

Recent Evidence That Health IT Improves Patient Safety: Issue Brief.

May 13, 2015

Promoting Patient Safety Through Effective Health Information Technology Risk Management.

July 23, 2014

FDASIA Health IT Report: Proposed Strategy and Recommendations for a Risk-Based Framework.

April 30, 2014

Strategy on Reducing Regulatory and Administrative Burden Relating to the Use of Health IT and EHRs.

December 12, 2018

Safety Assurance Factors for EHR Resilience: SAFER Guides.

January 29, 2014

How to Identify and Address Unsafe Conditions Associated With Health IT.

December 18, 2013

Solicitation for written comments on draft National Action Plan for Adverse Drug Event Prevention.

September 18, 2013

Health IT Patient Safety Action and Surveillance Plan.

July 17, 2013

Ten Years After Keeping Patients Safe: Have Nurses' Work Environments Been Transformed?

April 2, 2014

Accountability: Patient Safety and Policy Reform.

March 6, 2005

Achieving Excellence in Cancer Diagnosis: Proceedings of a Workshop—in Brief.

October 5, 2021 - October 6, 2021

The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, and Staff.

April 20, 2022

Meeting the Moment: Addressing Barriers and Facilitating Clinical Adoption of Artificial Intelligence in Medical Diagnosis.

October 12, 2022

Opportunities to Improve Patient Safety, Advancing U.S. Innovation, and Innovation Hubs.

October 5, 2022

Artificial Intelligence in Health Care: The Hope, the Hype, the Promise, the Peril.

December 1, 2019

Advancing Diagnostic Excellence for Older Adults: Proceedings of a Workshop in Brief.

July 21, 2022 - July 21, 2022

Lessons Learned from the COVID-19 Pandemic to Improve Diagnosis. Proceedings of a Workshop–in Brief.

May 11, 2022

Factors differentiating nursing homes with strong resident safety climate: a qualitative study of leadership and staff perspectives.

February 15, 2023

View More

Related Resources

National Healthcare Quality and Disparities Reports.

January 9, 2024

Final Report on Prioritization of Patient Safety Practices for a New Rapid Review or Rapid Response. Making Healthcare Safer IV Series.

August 9, 2023

Drugmakers are abandoning cheap generics, and now US cancer patients can’t get meds.

July 5, 2023

Inside the preventable deaths that happened within a prominent transplant center.

June 28, 2023

AI in medicine needs to be carefully deployed to counter bias – and not entrench it.

June 21, 2023

Towards safe conversational agents in healthcare.

June 14, 2023

Care Post-Roe: Documenting Cases of Poor-quality Care Since the Dobbs Decision.

June 7, 2023

Patient Safety Innovations

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

May 31, 2023

Hospitals in two states denied an abortion to a miscarrying patient. Investigators say they broke federal law.

May 31, 2023

Why do so many Black women die in pregnancy? One reason: doctors don't take them seriously.

May 31, 2023

Death Inside Lemuel Shattuck Hospital: A Case Study on Medical Treatment for Persons with Mental Health Disabilities.

May 24, 2023

Nurse Staffing Standards for Hospital Patient Safety and Quality Care Act of 2023.

May 10, 2023

Why hospitals still make serious medical errors—and how they are trying to reduce them.

March 29, 2023

Crisis in the Lakeshore Hospital ER.

March 8, 2023

Inadequate Outpatient Mental Health Triage and Care of a Patient at the Chico Community-Based Outpatient Clinic in California.

March 1, 2023

Maternal and Infant Health Inequality: New Evidence from Linked Administrative Data.

February 22, 2023

Bleeding and in pain, a pregnant woman in Louisiana couldn’t get answers.

January 25, 2023

During in-flight emergencies, sometimes airlines’ medical kits fall short.

January 18, 2023

Cybersecurity is Patient Safety: Policy Options in the Health Care Sector.

December 14, 2022

'Reading the Signals' : Maternity and Neonatal Services in East Kent – the Report of the Independent Investigation.

November 16, 2022

The National Healthcare System Action Alliance for Patient and Workforce Safety.

November 14, 2022 - November 14, 2022

Artificial Intelligence in Health Care: Benefits and Challenges of Machine Learning Technologies for Medical Diagnostics.

October 26, 2022

Comprehensive Healthcare Inspection Summary Report: Evaluation of Care Coordination in Veterans Health Administration Facilities, Fiscal Year 2021.

October 12, 2022

When medical error becomes personal, activism becomes painful.

September 28, 2022

'We had such trust, we feel such fools’: how shocking hospital mistakes led to our daughter’s death.

September 14, 2022

Concordance of hospital ranks and category ratings using the current technical specification of US Hospital Star Ratings and reasonable alternative specifications.

August 31, 2022

Risk reduction strategy to decrease incidence of retained surgical items.

August 31, 2022

How Safe is Your Care? Measurement and Monitoring of Safety Through the Eyes of Patients and Their Care Partners.

August 24, 2022

Abortion bans have consequences for wanted pregnancies, too.

August 17, 2022

Examining the Status of VA’s Electronic Health Record Modernization Program.

August 10, 2022

View More

See More About The Topic

Information Professionals

Medication Errors/Preventable Adverse Drug Events

Medical Complications

To sign up for updates or to access your subscriber preferences, please enter your email address below.

5600 Fishers Lane
Rockville, MD 20857
Telephone: (301) 427-1364