Report Summary

Title: Medication Management, Dispensing, and Administration Deficiencies at the VA Maryland Health Care System, Perry Point, Maryland
Report Number: 17-05742-66 Download
Issue Date: 2/6/2019
City/State: Perry Point, MD
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: Healthcare Inspection
Release Type: Unrestricted

The VA Office of Inspector General (OIG) conducted a healthcare inspection in response to a request from the OIG Office of Investigations to review the care of a patient at the Perry Point VA Medical Center, Maryland. The patient died in the hospice unit after receiving a potential overdose of a pain medication solution (oxycodone).

Pharmacy Service staff dispensed oxycodone solution in one bulk bottle for multiple patients, including the identified patient, rather than in unit doses, which contributed to processes that increased risks in all phases of medication management. Additionally, pharmacists inconsistently processed medication orders. The facility’s established process for administering oxycodone solution contributed to additional risk as nurses did not have tools to accurately measure the solution.

Facility leaders and patient safety program staff failed to recognize the inherent risks in medication administration and did not evaluate the patient’s death after receiving a potential medication overdose to determine the causes, system issues, and associated risks. Facility staff did not disclose the potential overdose to the patient’s family, conduct a root cause analysis or a peer review, or report it as an Adverse Drug Event to gain further understanding of the reasons and identify possible actions that could be taken to mitigate further risk. Facility staff did not follow requirements for ensuring recent acute care experience when hiring the nurse who administered the potential overdose and did not ensure the nurse’s competency related to the administration of this high-alert medication.

Due to the identified medication management issues, the OIG was unable to determine whether the potential overdose contributed to the patient’s death.

The OIG made eight recommendations related to evaluating and addressing the inaccuracies and risks involved with use of bulk bottles of oxycodone solution, quality review of the patient’s death, nurse hiring, and competencies processes.