Health Inspection: VistA Outages Affecting Patient Care Office of Risk Management and Incident Response Falling Waters, WV

摘要

The VA Office of Inspector General (OIG), Office of Healthcare Inspections reviewed allegations that there are an increasing number of Veterans Health Information Systems and Technology Architecture (VistA) outages that affect patient care and that the Office of Risk Management and Incident Response (RMIR) does not perform risk management, but only reports incidents to higher echelons within the Office of Information and Technology (OI&T). We did substantiate the allegation that RMIR was only reporting system outages via Daily Incident Reports to higher echelons and does not manage, track, or trend risks related to system outages. Further investigation revealed substandard maintenance practices and an aging infrastructure that contributed to the loss of this critical patient care system. No patient safety incidents were reported, but the after action report and staff interviews showed that patient care was seriously affected. The Root Cause Analysis Report revealed that the system outage was caused by hard disk failures in conjunction with outdated storage system firmware. OI&T maintenance had not performed a firmware upgrade which had been directed by the vendor 2 years prior. In addition, a report from the vendor identified significant issues relating to the aging infrastructure with critical recommendations that OI&T has not addressed.