Report Summary

Title: Medication Management Deficiencies after the New Electronic Health Record Go-Live at the Mann-Grandstaff VA Medical Center in Spokane, Washington
Report Number: 21-00656-110 Download
Report
Issue Date: 3/17/2022
City/State: Spokane, WA
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: Hotline Healthcare Inspection
Release Type: Unrestricted
Summary:

This report details the OIG’s healthcare inspection to assess a range of allegations regarding medication management deficiencies and potential patient safety issues associated with implementation of the new electronic health record (new EHR) at the Mann-Grandstaff VA Medical Center in Spokane, Washington.

The OIG found that the new EHR implementation was deficient in numerous areas affecting medication management, including (1) data migration issues leading to inaccurate contact information and medication lists; (2) medication order processes erroneously discontinuing certain medications, permitting registered nurses to enter orders without authorization, and failing to notify providers of important prescribing information; and (3) medication reconciliation processes being impeded by incomplete medication lists that led to staff developing time-consuming workarounds, which increased risks of errors.

Many of the medication management deficiencies remained unresolved during the OIG’s inspection from January to early June 2021. Although the OIG did not identify any associated patient deaths during this inspection, deployment of the new EHR without resolution of deficiencies may present risks to patient safety and affect providers’ treatment decisions.

Findings can be found in two companion reports related to clinical care coordination issues after going live, concerns identified with the process for addressing “tickets” for resolving problems, and factors that contributed to deficiencies.

The OIG made two recommendations to the Deputy Secretary: Ensure that substantiated and unresolved allegations are reviewed and addressed, and notify the OIG of any other medication management issues identified after the healthcare inspection. VA concurred with the first recommendation but not with the second, stating the recommendation creates a continuous reporting requirement to the OIG that prevents its closure. The OIG reminded the VA of its duty to provide this information and will close the recommendation when VA demonstrates an effective and sustainable process to identify and address patient safety issues.