VA EHR Modernization Linked to Veteran Deaths, Senate Report Says

The Senate Committee on Veterans’ Affairs reported that four veterans have died in connection with the VA’s ongoing EHR modernization initiative, three of them in Ohio. Investigations point to medication data drop-offs, faulty scheduling queue logic, and pharmacy function failures as major contributing factors.

Why It Matters

• Scale amplifies risk: At national programs like VA’s, even a single EHR logic error can cascade into widespread patient safety incidents. CIOs must treat large-scale rollouts as high-stakes operations with zero tolerance for defects.
• Governance and auditability: Vendors must provide transparent traceability—error logs, reconciliation tools, and rollback options. Black-box systems aren’t acceptable when lives are on the line.
• Safety testing must precede go-lives: Simulation, phased go-lives, and clinical validation should be required months ahead of production cutovers. Safety must be baked in, not bolted on. All workflows must be accounted for!
• Stakeholder management: For highly scrutinized implementations, CIOs need to act as visible stewards of risk management—building trust with clinicians, leadership, and the public.
• Modular deployment is safer: Rather than big-bang launches, isolating critical modules (like pharmacy) for incremental rollouts can contain risk and make failures manageable.