WASHINGTON – Leaders at Spokane’s VA medical center filed a report warning of potentially “severe” harm to a veteran who was hospitalized with heart failure in March after a troubled computer system contributed to a vital medication not being renewed, the Department of Veterans Affairs confirmed.
The patient was discharged after five days at Mann-Grandstaff VA Medical Center and was “well” a month later, VA Press Secretary Terrence Hayes said Thursday. But doctors considered the incident serious enough to report it as a “sentinel event,” prompting an investigation to prevent a similar occurrence in the future.
Since October 2020, Mann-Grandstaff and its associated clinics in Spokane, Coeur d’Alene, Wenatchee, Sandpoint and Libby, Montana, have been the pilot sites for an electronic health record system developed by Cerner Corp. in a $16 billion effort to replace an older system still used at other VA facilities to track patient information and coordinate care.
After the veteran was admitted to the hospital on March 15 for heart failure, clinicians discovered a heart medication that had been prescribed before the Cerner system’s launch had disappeared from a list of the patient’s active medications when the prescription expired a year after it was written, Hayes said in a written response to questions from The Spokesman-Review.
The missing medication had not been noticed during the veteran’s subsequent visits to Mann-Grandstaff and the prescription was not renewed as it should have been, Hayes said, which “likely contributed to his hospitalization.” When the hospital’s clinical leaders reviewed the case March 18, they determined the error had “the potential for temporary severe harm” and met the definition of a sentinel event.
While VA officials have previously acknowledged patient safety risks related to the Cerner system – which has frustrated veterans and left Mann-Grandstaff employees exhausted and demoralized, a Spokesman-Review investigation found – the incident in March highlights the severity of medication-related problems workers in Spokane have warned about for more than a year.
The sentinel event designation was created by the Joint Commission, an organization that accredits hospitals and monitors patient safety across the United States. It refers to an incident “not primarily related” to a patient’s illness or underlying condition that results in death, permanent harm or “severe temporary harm.”
Asked whether the Joint Commission would investigate the incident in March, Hayes pointed out that accredited organizations aren’t required to report sentinel events to the accrediting body, but added that Mann-Grandstaff had taken “appropriate and timely action” to evaluate the case. According to Joint Commission policy, accredited hospitals are “strongly encouraged” to report sentinel events, but are not required to do so.
In his written responses, Hayes pointed out that prescriptions are supposed to expire after one year, forcing providers to follow up with their patients and renew the medications if needed. The prescription that dropped off the patient’s active medication list with the launch of the Cerner system, he said, was “most likely already expired” in the previous system before the transition in October 2020 and could be viewed on a separate “historical medications” page in the new Cerner system.
Hayes said VA doesn’t view prescriptions dropping off the active medication list when they expire as a problem, but rather as “the system working as designed” to ensure oversight, adding that medical providers should verify all of a patient’s medications during every appointment and renew them as needed.
But five Mann-Grandstaff clinicians who have encountered the problem of prescriptions disappearing from a medication list said they were not given adequate training by VA or Cerner on a new process they described as unintuitive and potentially dangerous.
After VA confirmed the incident, The Spokesman-Review agreed to protect the identities of the five clinicians to provide details about medication problems in the new computer system. The clinicians said they fear retaliation for speaking publicly.
The clinicians explained that when “legacy” prescriptions written before the Cerner transition expired, they moved from a patient’s active medication list to a separate list of inactive medications, which could contain dozens of old prescriptions dating back many years. In the old system, prescriptions were labeled “expired” a year after they were written but remained on the active medication list, prompting a provider to renew them if needed.
Hayes said Mann-Grandstaff is aware of only “two instances in which a legacy medication dropped off the active medical list at the one-year anniversary of the prescription being written,” and confirmed that both patients were “known to be well” as of Thursday.
The clinicians said the Cerner system appeared to treat expired prescriptions written before October 2020 as if they had been discontinued by a doctor, when in fact they should have been renewed. For the treatment of chronic conditions, which veterans suffer at a higher rate than the general population, this could increase the risk of important medications being stopped by mistake.
The clinicians said they have received calls from veterans who have noticed important prescriptions being stopped, allowing them to quickly correct the mistake. But they said some veterans assume that when a medication is not renewed, it means they don’t need to take it anymore. While providers do confirm a patient’s medications during every appointment, they added, the Cerner system moved the expired prescriptions to a separate page they didn’t know they had to check.
While the Cerner system may not have been the sole cause of the sentinel event in March, the incident illustrates the additional burden the system places on veterans and health care providers to prevent potentially life-threatening errors.
Studies have shown VA hospitals generally provide higher-quality care and better health outcomes than other health care providers, and veterans who rely on Mann-Grandstaff have complimented the care they receive and expressed their gratitude to hospital’s employees in past interviews with The Spokesman-Review. But the clinicians said the extra degree of vigilance required to prevent problems related to the new system has left them frustrated and exhausted.
A spokesman for Cerner deferred questions about the sentinel event and the medication list issue to VA.
The issue that likely contributed to the veteran’s heart failure in March is just one of dozens of problems associated with the Cerner system the VA Office of Inspector General corroborated in a trio of reports released March 17. In one of the three reports, the internal watchdog agency substantiated 21 different medication-related problems reported by employees, all of which remained unresolved when the office completed its inspection in late June 2021.
In the wake of those reports, both Rep. Cathy McMorris Rodgers, R-Spokane, and Sen. Patty Murray, D-Wash., called for VA to delay the rollout of the Cerner system before it launched in Walla Walla on March 26, but VA officials have said lessons learned from Spokane will help other sites avoid similar problems. Hayes, the VA press secretary, confirmed that Mann-Grandstaff will continue using the system while the sentinel event in March is investigated.
One of the primary problems, the clinicians said, is that the main program in the Cerner system, called PowerChart, doesn’t effectively communicate with the system’s pharmacy module. For instance, PowerChart may show a doctor that a patient’s prescription has a refill remaining while a pharmacist sees no refills available.
Rep. Matt Rosendale of Montana, the top Republican on a House subcommittee charged with oversight of the system’s rollout, highlighted that issue in an April 8 letter to top VA and Cerner officials, calling it “the single greatest technical problem with the Cerner (system).”
Writing to VA Deputy Secretary Donald Remy and Travis Dalton, president of Cerner Government Services, the congressman said he had been told fixing the problem would take about two years and demanded that timeline be accelerated.
“It is clearly necessary to make the EHR system fully functional, and I question why it was not originally part of the Cerner contract,” Rosendale wrote, adding that Mann-Grandstaff personnel had highlighted the problem at least six months earlier. “The Electronic Health Record Modernization program is already perilously behind in addressing this problem, and knowingly spreading it to other medical centers’ pharmacies would be irresponsible.”
After the VA hospital in Walla Walla – along with its clinics in Washington, Idaho and Oregon – became the second site to adopt the Cerner system on March 26, it is set to launch April 30 in Columbus, Ohio. Other planned rollouts this year include Roseburg and White City, Oregon, on June 11; Boise on June 25; Anchorage, Alaska, on July 16; Seattle and American Lake on Aug. 27; three sites in Michigan on Oct. 8; and Portland on Nov. 5.
Remy, the top VA official in charge of the Cerner system’s nationwide rollout, is scheduled to visit Mann-Grandstaff on Monday.
Top VA officials, Cerner executives and VA’s deputy inspector general will testify before a House subcommittee about the problems at Mann-Grandstaff at 11 a.m. PDT on Tuesday. The hearing will be live-streamed on the panel’s website, accessible via the following address: tinyurl.com/VAhearing