Healthcare Inspection - Medication Management Issues in a High Risk Patient, Tuscaloosa VAMC, Tuscaloosa, Alabama

OIG conducted an evaluation in response to allegations that providers at the Tuscaloosa VA medical center (facility) mismanaged opioid therapy for a high-risk patient and that facility managers did not take appropriate actions after the patient’s death. We substantiated that facility providers collectively prescribed oxycodone, methadone, and benzodiazepines to a high-risk patient who died of an accidental multi-drug overdose. Three factors contributed to this outcome: (1) The patient’s primary care provider (PCP) did not consistently complete key elements of the pain assessment, initiate an opioid pain care agreement, ensure adequate patient monitoring and follow-up after prescribing methadone, or document patient education regarding the specific dangers of methadone; (2) the facility did not ensure access to an interdisciplinary pain management team or Pain Clinic to provide needed services to this patient; and (3) the PCP, mental health provider, and Suicide Prevention Coordinator did not ensure communication and coordination of care for this high-risk patient. We did not substantiate that the facility covered up the patient’s subsequent visit to the facility or delayed the autopsy report. However, the facility did not comply with selected aspects of VHA Directives on clinical reviews and patient safety processes. We made seven recommendations.