WASHINGTON – Leaders at Spokane’s VA medical center filed a report warning of potentially “severe” harm to a veteran who was hospitalized with heart failure in March after a troubled computer system contributed to a vital medication not being renewed, the Department of Veterans Affairs confirmed.
The patient was discharged after five days at Mann-Grandstaff VA Medical Center and was “well” a month later, VA Press Secretary Terrence Hayes said Thursday. But doctors considered the incident serious enough to report it as a “sentinel event,” prompting an investigation to prevent a similar occurrence in the future.
Since October 2020, Mann-Grandstaff and its associated clinics in Spokane, Coeur d’Alene, Wenatchee, Sandpoint and Libby, Montana, have been the pilot sites for an electronic health record system developed by Cerner Corp. in a $16 billion effort to replace an older system still used at other VA facilities to track patient information and coordinate care.
After the veteran was admitted to the hospital on March 15 for heart failure, clinicians discovered a heart medication that had been prescribed before the Cerner system’s launch had disappeared from a list of the patient’s active medications when the prescription expired a year after it was written, Hayes said in a written response to questions from The Spokesman-Review.
The missing medication had not been noticed during the veteran’s subsequent visits to Mann-Grandstaff and the prescription was not renewed as it should have been, Hayes said, which “likely contributed to his hospitalization.” When the hospital’s clinical leaders reviewed the case March 18, they determined the error had “the potential for temporary severe harm” and met the definition of a sentinel event.
While VA officials have previously acknowledged patient safety risks related to the Cerner system – which has frustrated veterans and left Mann-Grandstaff employees exhausted and demoralized, a Spokesman-Review investigation found – the incident in March highlights the severity of medication-related problems workers in Spokane have warned about for more than a year.
The sentinel event designation was created by the Joint Commission, an organization that accredits hospitals and monitors patient safety across the United States. It refers to an incident “not primarily related” to a patient’s illness or underlying condition that results in death, permanent harm or “severe temporary harm.”
Asked whether the Joint Commission would investigate the incident in March, Hayes pointed out that accredited organizations aren’t required to report sentinel events to the accrediting body, but added that Mann-Grandstaff had taken “appropriate and timely action” to evaluate the case. According to Joint Commission policy, accredited hospitals are “strongly encouraged” to report sentinel events, but are not required to do so.
In his written responses, Hayes pointed out that prescriptions are supposed to expire after one year, forcing providers to follow up with their patients and renew the medications if needed. The prescription that dropped off the patient’s active medication list with the launch of the Cerner system, he said, was “most likely already expired” in the previous system before the transition in October 2020 and could be viewed on a separate “historical medications” page in the new Cerner system.
Hayes said VA doesn’t view prescriptions dropping off the active medication list when they expire as a problem, but rather as “the system working as designed” to ensure oversight, adding that medical providers should verify all of a patient’s medications during every appointment and renew them as needed.
But five Mann-Grandstaff clinicians who have encountered the problem of prescriptions disappearing from a medication list said they were not given adequate training by VA or Cerner on a new process they described…
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