Veterans’ heart issues reveal flaws with new tracking system –
Pilot sites are reporting issues with the new system, including active medications removed from patient records.
Administrators at the Veterans Affairs (VA) Medical Center in Spokane, Wash., filed a warning citing possible “serious harm” to a person hospitalized with heart failure last month. According to the Department of Veterans Affairs, the site’s new computerized medication tracking system is causing some medications not to be replenished as they should, and the affected patient was released after five days at Mann-Grandstaff VA Medical Center. Until a month later, the patient was doing “well,” according to VA publicist Terrence Hayes. However, doctors deemed the harm caused to be serious enough to flag a ‘sentinel event’ and further investigation is currently underway.
As of October 2020, Mann-Grandstaff, Coeur d’Alene, Wenatchee, Sandpoint, and Libby, Montana, VA facilities have been named pilot sites for an electronic health record tracking system developed by Cerner Corp., which is part of a $16 billion effort. to replace an obsolete system. The veteran subject of the report was admitted to Mann-Grandstaff in mid-March for heart failure. The medical team discovered that a heart medication that had previously been prescribed to prevent organ failure was removed from the veteran’s current prescription list once the new system was rolled out.
It had “expired a year after it was written”, Hayes said, adding that the missing medication had not been noticed and not refilled, which “probably contributed to his hospitalization”. The team reviewed the case on March 18 and found the error had “the potential to cause serious temporary damage,” according to their report. To qualify as a “sentinel event”, a term instituted by the Joint Commission, an incident must “not be primarily related to a patient’s illness or underlying condition resulting in death, permanent harm or serious temporary damage”.
Hayes said accredited programs “are not required” to report these types of events, but that Mann-Grandstaff had taken “appropriate and timely steps” to evaluate the tracking system. In fact, he said prescriptions expire after a year to ensure providers follow up on patients. When the center introduced the Cerner system, it was likely scrapped because it had “already expired.” So the system was working properly.
However, the medical team said they had already seen prescriptions disappear from medication lists and that they had not been trained enough to navigate the Cerner program. According to the team, “legacy” prescriptions were automatically moved from a patient’s active list to a separate list of inactive medications. They received calls from veterans who noticed large prescriptions suddenly being cut off. Clinical staff added that the Cerner system “appeared to treat expired prescriptions written before October 2020 as if they had been paused by a physician, when in fact they should have been renewed.”
Mann-Grandstaff, according to Hayes, “is only aware of two cases in which a legacy drug was removed from the active medical list on the one-year anniversary of the writing of the prescription”, and he has confirmed that both patients are “known to be in good health”. .” However, the March incident highlights the potential for critical errors, and clinicians said “the extra degree of vigilance required to prevent problems with the new system has left them frustrated and exhausted.”