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

July 27, 2022

Washington, DC: VA Office of the Inspector General; July 14 2022. Report No. 22-01137-204.

Problems with clinician order delivery can result in harmful care delays. This report discusses how an electronic health record (EHR) system sent thousands of requests for medical care in a large health system to no location rather than to the intended site for care. These misattributions contributed to 142 patient safety events. The analysis highlighted factors contributing to the EHR misdistribution of orders and shared concerns that the organization’s approach to reduce the risk for misrouted orders lacks effectiveness.

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