VA Oracle Cerner electronic health record rollout failures
The US Department of Veterans Affairs' new Oracle Cerner electronic health record system was linked to patient-safety incidents, including missed and duplicated medication orders, at VA facilities where it was deployed, prompting Congress to pause further rollout.
The damage was public. The root cause was preventable.
The US Department of Veterans Affairs' new Oracle Cerner electronic health record system was linked to patient-safety incidents, including missed and duplicated medication orders, at VA facilities where it was deployed, prompting Congress to pause further rollout.
What the software actually got wrong
VA's Office of Inspector General found that the new software's design routed certain orders into an 'unknown queue' that clinicians did not know to check, so time-sensitive medication and referral orders could silently go unseen rather than reaching the intended care team.
VA's Office of Inspector General found that the new...
VA's Office of Inspector General found that the new software's design routed certain orders into an 'unknown queue' that clinicians did not know to check, so time-sensitive medication and referral orders could silently go unseen rather than reaching the intended care team.
Requs AI Edge Case flags this exact pattern at the requirements and architecture stage — before a single line of code implementing it exists — so the assumption behind it gets challenged while it is still cheap to fix.
Beyond code coverage and "shall" testing
Root causes like this one rarely show up in code coverage or requirements-compliance testing, because nobody wrote a requirement anticipating the specific edge case that broke. Requs AI Edge Case and Requs AI Software FMEA are built to surface exactly this class of overlooked failure mode — before the software is written.
Surfaces this before code exists
Identifies edge cases like this one at requirements and architecture time, using the Common Defect Enumeration to catalog failure patterns seen across hundreds of real-world software failures — including this one.
Connects the failure mode to the hazard
Traces this class of root cause directly to the system-level hazard it can produce, so a defect pattern like this one gets flagged during design review instead of after it ships.
Find the overlooked root causes before they ship.
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