Concerns Related to the Management of a Patient’s Medication at Three VA Medical Centers and Inaccurate Response to a Congressional Inquiry at the VA Illiana Health Care System, Danville, Illinois

Report Information

Issue Date
Report Number
18-02056-54
VISN
State
Florida
Illinois
Indiana
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Recommendations
8
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
This healthcare inspection assessed allegations that over a multi-year period, providers at three facilities ordered or continued to order a high dose of an antidepressant medication amitriptyline for a patient who was not told about the risks of the high dose, and was experiencing some side effects associated with the medication. Additionally, when asked about attempts to reduce the dose of the patient’s medication, the VA Illiana Health Care System (system) in Danville, Illinois, provided Senator Joe Donnelly inaccurate information. The Office of Inspector General (OIG) substantiated VA providers did not explain to the patient that the amitriptyline dosing was higher than the drug labeling for outpatients or the risks of the high dosage during the period of care from 2012 through mid-2018. In 2012, a provider at the Orlando VA Medical Center (VAMC) in Florida ordered an electrocardiogram but did not inform the patient about an abnormality or discuss the potential that the high dose of amitriptyline contributed to the abnormality. At another VAMC in Indianapolis, Indiana, the ordering provider did not notify the patient that 2016 test results indicated a subtherapeutic level of amitriptyline. At the system, there was no follow-up to the patient’s expressed cardiac concerns due to a failed collaboration between the system’s treating psychiatrist and a primary care provider. Due to other potential causes, the OIG was unable to substantiate the patient experienced tachycardia or short-term memory loss because of taking amitriptyline. The system’s response to Senator Donnelly was not timely and included inaccurate information. The OIG made eight recommendations related to evaluations of the patient’s cardiac care, patient notification of electrocardiograms and blood tests, the strengthening of system processes for effective clinical consultation between providers and congressional inquiry responses, and an evaluation of system staff actions in preparation of the letter to Senator Donnelly.

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Orlando VA Medical Center Director evaluates the care of the subject patient with respect to the patient’s cardiac complaints and takes action, as appropriate, including clinical disclosure.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Orlando VA Medical Center Director verifies staff compliance with Veterans Health Administration policies related to patient notification of electrocardiogram test results and follow-up as clinically indicated.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Richard L. Roudebush VA Medical Center Director evaluates the care of the subject patient with respect to the patient’s cardiac complaints and takes action, as appropriate, including clinical disclosure.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Richard L. Roudebush VA Medical Center Director verifies staff compliance with Veterans Health Administration policies related to patient notification of medication blood level test results and follow-up as clinically indicated.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The VA Illiana Health Care System Director evaluates the care of the subject patient with respect to the patient’s cardiac complaints and takes action, as appropriate, including clinical disclosure.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The VA Illiana Health Care System Director strengthens processes for effective clinical consultation and follow-up between mental health and collaborating primary care providers.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The VA Illiana Health Care System Director strengthens the processes for congressional inquiry response to ensure response timeliness, clinical information accuracy, and records retention, as required.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The VA Illiana Health Care System Director evaluates staff actions and approval processes in the preparation of the letter to Senator Donnelly, and takes appropriate administrative action, if indicated.