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Veteran’s Heart Issues Expose Flaws with New Tracking System

— April 27, 2022

Pilot sites report issues with new system, including active medications being dropped off of patient charts.

Administrators at Spokane, Washington’s Veterans Affairs (VA) medical center have filed a warning citing possible “severe harm” to an individual hospitalized for heart failure last month.  The site’s new computer medication tracking system causes certain medications to not be renewed as they should be, according to the Department of Veterans Affairs, and the patient impacted by this was discharged after five days at Mann-Grandstaff VA Medical Center.  Up to a month later, the patient was “well,” according to VA Press Secretary Terrence Hayes.  However, physicians felt the harm done was serious enough to report a “sentinel event” and a subsequent investigation is currently underway.

Since October 2020, the VA’s Mann-Grandstaff, Coeur d’Alene, Wenatchee, Sandpoint and Libby, Montana, facilities have been named pilot sites for an electronic health records tracking system developed by Cerner Corp., which is part of a $16 billion effort to replace an outdated system.  The veteran who is the subject of the report was admitted to Mann-Grandstaff in mid-March for heart failure.  The medical team found a heart medication that had been previously prescribed to avoid organ failure had dropped from the veteran’s list of current prescriptions once the new system was rolled out.

Veteran's Heart Issues Expose Flaws with New Tracking System
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It had “expired a year after it was written,” Hayes said, adding that the missing medication hadn’t been noticed and it wasn’t renewed, which “likely contributed to his hospitalization.”  The team reviewed the case on March 18 and found the error had “the potential for temporary severe harm,” according to their report.  To be deemed a “sentinel event,” a term instituted by the Joint Commission, an incident has to be “not primarily related to a patient’s illness or underlying condition that results in death, permanent harm or severe temporary harm.”

Hayes said that accredited programs “aren’t required” to report these types of events, but that Mann-Grandstaff had taken “appropriate and timely action” to evaluate the tracking system.  In fact, he indicated that prescriptions expire after one year to ensure providers follow up with patients.  When the center implemented the Cerner system, it was likely removed because it had “already expired.”  Thus, the system was actually working properly.

However, the medical team said that they’ve witnessed prescriptions disappearing from medication lists before and that they were not adequately trained on navigating the Cerner’s program. According to the team, “legacy” prescriptions were automatically moved from a patient’s active list to a separate list of inactive medications.  They’ve received calls from veterans who have noticed important prescriptions being suddenly discontinued.  Clinical personnel added that the Cerner system “appeared to treat expired prescriptions written before October 2020 as if they had been discontinued by a doctor, when in fact they should have been renewed.”

Mann-Grandstaff, according to Hayes, “is aware of only two instances in which a legacy medication dropped off the active medical list at the one-year anniversary of the prescription being written,” and he confirmed both patients are “known to be well.”  However, the incident which occurred in March highlights the potential for critical errors to be made, and the clinicians said the “extra degree of vigilance required to prevent problems related to the new system has left them frustrated and exhausted.”


Veteran hospitalized at Spokane VA after missing heart medication, highlighting health record system’s prescription problems

VA delays first go-live of Cerner EHR system as project takes longer than expected

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