Veteran hospitalized after medication dropped from EHR list

Veteran hospitalized after medicine dropped from EHR record

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Reviews emerged this week of a veteran hospitalized in March after a coronary heart medicine prescription went lacking from his “lively prescription” record.  

As first reported by the Spokesman-Evaluate’s Orion Donovan-Smith, scientific management at Mann-Grandstaff VA Medical Middle in Spokane, Washington, characterised the incident as a “sentinel occasion” upon reviewing the case.  

The issue appeared to stem, partly, from a heart-failure medicine that had been prescribed earlier than the October 2020 go-live of a brand new Cerner digital well being document system at Mann-Grandstaff.  

The drug had moved off an inventory of the affected person’s lively drugs on the one-year anniversary of the prescription being written, and was not renewed as vital.  

“This doubtless contributed to his hospitalization in March of 2022” for decompensated coronary heart failure, VA representatives instructed Healthcare IT Information.  

“Cerner continues to work intently with VA suppliers and workers to iterate on coaching and alter administration,” stated Cerner representatives in response to requests for remark.   

“Affected person security is prime of thoughts and reinforces the necessity for all suppliers and workers enterprise-wide to leverage the scientific determination help instruments accessible within the EHR,” representatives continued.   

“Cerner is redoubling efforts with VA to make sure suppliers in any respect services are snug managing prescriptions within the new system by refined coaching,” they added.  


VA representatives defined to Healthcare IT Information that the veteran’s coronary heart medicine prescription may nonetheless be seen beneath a “historic drugs” space of the brand new Cerner system.

The prescription in query was “more than likely already expired” within the VA’s legacy EHR system, stated representatives.  

“When it comes to actions taken, VA healthcare professionals proceed to take care of the present protocol for affected person prescriptions: Prescriptions are scheduled to run out after a yr, forcing medical suppliers to observe up with their sufferers’ progress,” they instructed Healthcare IT Information.   

“This isn’t seen as a problem, however is the system working as designed to make sure correct oversight of medicine therapies. Prescriptions will not be given to sufferers with out an expiration date,” they stated. Suppliers ought to reconcile all drugs throughout each encounter with a view to confirm and renew as wanted, they stated.

In accordance with the VA, the hospital’s scientific leaders decided that the March incident met the definition of a sentinel occasion, provided that it “led to the potential for non permanent extreme hurt.” 

The affected person in query was discharged after 5 days within the hospital and is at the moment “confirmed to be properly.”  

“Mann-Grandstaff VA Medical Middle is conscious of two cases during which a legacy medicine dropped off the lively medical record on the one-year anniversary of the prescription being written. Each sufferers are recognized to be properly right now,” stated representatives.  

“Cerner has up to date its coaching to emphasise the use case of non-Cerner-authored prescriptions (e.g., prescriptions authored in VistA, the VA legacy system, and migrated to the Cerner system) and the way these may be seen within the affected person’s document,” they continued. “Cerner continues to work with VA on enhancements that can present most visibility of prescriptions in most of these medicine administration conditions.”  

VA officers instructed members of the media in a press convention on Monday that they continued to get updates from each Spokane and the VA facility in Walla Walla.  

Secretary Denis R. McDonough declined to remark intimately concerning the case, citing affected person privateness points. Requested about potential affected person hurt from EHR errors, he stated, “I’m not conscious of every other incident.”  

Total, he stated, “I proceed to consider that now we have the price range authority we want over the lifetime of this mission.”  


Remedy administration has been one of many considerations cited by lawmakers relating to the VA’s EHR modernization initiative.   

In March of this yr, U.S. Senator Patty Murray, D-Wash., issued an announcement asking the VA to cease its deliberate March 26 go-live in Walla Walla. Her request adopted experiences launched by the VA Workplace of Inspector Normal, one in all which detailed allegations about medicine administration.  

And earlier this month, Rep. Matt Rosendale, R-Mont., requested VA and Cerner management on Friday to implement what he referred to as a “true” bidirectional interface between the EHR and its pharmacy module.  

“Pharmacists on the Mann-Grandstaff VA Medical Middle, the Jonathan M. Wainwright VA Medical Middle and any subsequent websites will wrestle with a needlessly difficult, time-consuming, error-prone, double-entry course of to prescribe medicine that saps productiveness and places veterans in danger,” stated Rosendale.  


“We stay dedicated to working with VA to get this proper for our veterans who’re deserving of fast, secure and efficient care,” stated Cerner representatives.

Kat Jercich is senior editor of Healthcare IT Information.
Twitter: @kjercich
E mail: [email protected]
Healthcare IT Information is a HIMSS Media publication.

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