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Software glitches put vets at risk

Thu., Jan. 15, 2009

VA medical center patients exposed to incorrect drug doses, other errors

WASHINGTON – The top Republican on the House Veterans Affairs Committee demanded Wednesday that the VA explain how it allowed software glitches to put the medical care of patients at its health centers nationwide at risk.

The glitches were discovered at nearly a third of the VA’s medical centers, including those in Spokane and Boise.

“I am deeply concerned about the consequences on patient care that could have resulted from this ‘software glitch’ and that mistakes were not disclosed to patients who were directly affected,” said Rep. Steve Buyer, R-Ind. “I have asked VA for a forensic analysis of all pertinent records to determine if any veterans were harmed, and I would like to know who was responsible for the testing and authorized the release of the new application.”

Patients at VA health centers were given incorrect doses of drugs, had needed treatments delayed and may have been exposed to other medical errors due to the glitches that showed faulty displays of their electronic health records, according to internal documents obtained by the Associated Press under the Freedom of Information Act.

The glitches, which began in August and lingered until last month, were not disclosed to patients by the VA even though they sometimes involved prolonged infusions for drugs such as blood-thinning heparin, which can be life-threatening in excessive doses.

There is no evidence that any patient was harmed, even as the VA says it continues to review the situation.

In Spokane, a statement released by the medical center late Wednesday said that no one was harmed as a result of the glitch in a patch released to update medical records. The medical center’s staff identified the problem and brought it to the attention of the VA in Washington, D.C.

“At the same time, the facility took steps to minimize potential adverse consequences by having several alternative systems in place for staff to track impacted patients’ treatment,” according to the statement.

The issue arose as the federal government begins promoting universal use of electronic medical records. President Bush has supported the effort and President-elect Barack Obama has made it a top priority, part of an additional $50 billion a year in spending for health information technology programs that he has proposed.

The VA’s recent glitches involved medical data – vital signs, lab results, active meds – that sometimes popped up under another patient’s name on the computer screen. Records also failed to clearly display a doctor’s stop order for a treatment, leading to reported cases of unnecessary doses of intravenous drugs such as blood-thinning heparin.

The agency noted that veterans with questions or concerns can request a copy of their medical record at any time, such as via the “My HealtheVet” online system at

In all, nearly one-third of the VA’s 153 medical centers reported seeing some kind of glitch, although the VA said that number could be higher since some facilities may not have filed reports.

Staff writer Kevin Graman contributed to this report.

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