VA's Oracle Cerner EHR System Has Caused 826 Major Patient Safety Incidents Including Deaths Since 2020

The Department of Veterans Affairs' $16 billion Oracle Cerner electronic health record (EHR) modernization has generated 826 documented 'major performance incidents' between October 2020 and March 2024, collectively disrupting EHR availability for 1,909 hours (nearly 80 days), with confirmed patient harms including at least one death. At the Mann-Grandstaff VA Medical Center in Spokane, Washington -- the first facility to receive the system -- over 11,000 veterans' clinical orders were routed to an 'unknown queue,' directly harming at least 149 veterans. A separate incident at the VA Central Ohio Healthcare System contributed to a patient's accidental overdose death. As of late 2025, staff report patient notes disappearing, prescriptions displaying incorrect dosages, and data anomalies that endanger patient safety. Why it matters: Veterans receive incorrect medications or their clinical orders vanish into unmonitored system queues, so patients experience direct physical harm including overdoses and delayed treatments, so veterans lose trust in VA healthcare and avoid seeking care, so the 61% of veteran suicide decedents who already do not use VA care grows even larger, so preventable veteran deaths increase while the government has spent $16 billion on the very system causing the harm. The structural root cause is that the VA and Oracle Health lack adequate controls to prevent system changes from causing major incidents, have no standardized incident response procedures, and have not provided interoperable downtime equipment to facilities -- meaning when the system fails, staff have no reliable backup process and patients fall through the cracks.