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

This report reviewed allegations relating to Veterans Health Information Systems and Technology Architecture (VistA) system outages that affect patient medical care and safety. The allegations were in response to a 23-hour VistA outage at the VA North Texas Healthcare System and alleged that the Office of Risk Management and Incident Response (RMIR) had no action requirement other than reporting the outage 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. We made recommendations for improvement and OI&T submitted appropriate implementation plans.