Veteran hospitalized after drugs removed from EHR list

Reports emerged this week of a veteran hospitalized in March after a prescription for heart medication disappeared from his ‘active prescription’ list.

As first reported by the Spokesperson-Review’s Orion Donovan-Smithclinical management at Mann-Grandstaff VA Medical Center in Spokane, Wash., called the incident “sentinel event“on examination of the file.

The problem appeared to stem, in part, from a heart failure drug that was prescribed before the October 2020 go-live of a new Cerner electronic health record system at Mann-Grandstaff.

The drug had been removed from the patient’s active medication list on the first anniversary of the writing of the prescription and had not been refilled when needed.

‘It likely contributed to his hospitalization in March 2022’ for decompensated heart failure, VA representatives said. Health Informatics News.

“Cerner continues to work closely with vendors and VA personnel to iterate on training and change management,” Cerner representatives said in response to requests for comment.

“Patient safety is a priority and reinforces the need for all providers and company personnel to take advantage of the clinical decision support tools available in the EHR,” the representatives continued.

“Cerner is working hard with VA to ensure providers at all facilities are comfortable managing prescriptions in the new system through refined training,” they added.


VA representatives explained to Health Informatics News that the veteran’s heart medication prescription could still be viewed in a “historic medication” area of ​​the new Cerner system.

The prescription in question was “most likely already expired” in the VA’s old EHR system, representatives said.

“In terms of actions taken, VA healthcare professionals continue to maintain the current protocol for patient prescriptions: prescriptions must expire after one year, requiring healthcare providers to track their patients’ progress,” they said. they stated. Health Informatics News.

“This is not considered a problem, but the system is working as intended to ensure proper monitoring of drug therapies. Prescriptions are not given to patients without an expiry date,” they said. Providers should reconcile all medications at each encounter to check and refill as needed, they said.

According to the VA, clinical officials at the hospital determined that the March incident met the definition of a sentinel event, as it “resulted in the potential for temporary serious harm.”

The patient in question was discharged after five days of hospitalization and is currently “confirmed that he is well”.

“Mann-Grandstaff VA Medical Center is aware of two cases in which a legacy medication was removed from the active medical list on the one-year anniversary of the prescription being written. Both patients are known to be fine right now,” representatives said.

“Cerner has updated its training to focus on the use case of non-Cerner written prescriptions (e.g. prescriptions written in VistA, VA legacy system and migrated to Cerner system) and how these These can be viewed in the patient’s record,” they continued. “Cerner continues to work with VA on enhancements that will provide maximum prescription visibility in these types of medication management situations.”

VA officials told members of the media at a press conference Monday that they continue to receive updates from Spokane and VA facilities in Walla Walla.

Secretary Denis R. McDonough declined to comment in detail on the case, citing patient confidentiality concerns. Asked about the potential harm to patients from EHR errors, he said: “I’m not aware of any other incidents.”

Overall, he said, “I continue to believe we have the budgetary authority we need throughout the life of this project.”


Medication management was one of the concerns cited by lawmakers regarding the VA’s EHR modernization initiative.

In March of this year, U.S. Sen. Patty Murray, D-Wash., released a statement asking the VA to halt its scheduled March 26 commissioning in Walla Walla. His request followed reports released by the VA’s Office of Inspector General, one of which detailed allegations about drug management.

And earlier this month, Rep. Matt Rosendale, R-Mont., asked VA and Cerner management on Friday to implement what he called a “true” two-way interface between the EHR and its pharmacy mod.

“Pharmacists at Mann-Grandstaff VA Medical Center, Jonathan M. Wainwright VA Medical Center, and all subsequent sites will struggle with an unnecessarily complicated, time-consuming, error-prone, and double-entry process for prescribing drugs that undermine the productivity and put veterans at risk,” Rosendale said.


“We remain committed to working with VA to make things right for our veterans who deserve prompt, safe and effective care,” Cerner representatives said.

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

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