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Report File
Date Issued
Submitting OIG
Department of Veterans Affairs OIG
Other Participating OIGs
Department of Veterans Affairs OIG
Agencies Reviewed/Investigated
Department of Veterans Affairs
Components
Veterans Health Administration
Report Number
23-01450-114
Report Description

The VA Office of Inspector General (OIG) conducted an inspection at the VA Central Ohio Healthcare System (facility) in Columbus to review an allegation that implementation of the new electronic health record (EHR) led to a prescription backlog. While reviewing the allegation, the OIG determined facility leaders took timely and sustainable steps to manage the issue. However, the OIG identified other facility and national pharmacy-related patient safety issues.The OIG found implementation of the new EHR at the facility, despite known pharmacy-related patient safety and usability issues, contributed to ongoing patient safety risks and usability challenges at the facility. The new EHR contributed to pharmacy-related patient safety issues nationally as a software coding error resulted in inaccurate medication and allergy information transmission from new EHR sites to legacy EHR sites. Affected patients were not notified of their risk of harm and the OIG remains concerned for their safety. The OIG learned VHA communicated recommendations to providers to mitigate the risk of harm to affected patients; however, the recommendations were non-sustainable. Additionally, the new EHR's operational inefficiencies required increased clinical pharmacist staffing and development of workarounds and educational materials to complete pharmacy processes. The inefficiencies also led to pharmacy staff burnout, job dissatisfaction, and decreased morale.The OIG made three recommendations to the Deputy Secretary related to resolution of patient safety and usability issues. The OIG made six recommendations to the Under Secretary for Health. One recommendation focuses on accurate patient medication data and three recommendations address patient and provider awareness and evaluation of the risk of harm related to data transmission issues. Another recommendation is related to pharmacy staffing, and one focuses on the underlying technical and functional issues requiring workarounds and educational materials to perform pharmacy operations.

Report Type
Inspection / Evaluation
Location

OH
United States

Number of Recommendations
8
Questioned Costs
$0
Funds for Better Use
$0

Open Recommendations

This report has 6 open recommendations.
Recommendation Number Significant Recommendation Recommended Questioned Costs Recommended Funds for Better Use Additional Details
01 No $0 $0

The Deputy Secretary ensures mitigation of the high-risk pharmacy-related patient safety issues identified during the May 2021 National Center for Patient Safety visit.

03 No $0 $0

The Deputy Secretary ensures the resolution of pharmacy-related usability issues identified in this report.

05 No $0 $0

The Under Secretary for Health determines the need for and implements a comprehensive strategy to review patients affected by inaccurate medication data transmitted to the Health Data Repository to evaluate whether harm occurred, the need for patients to undergo testing or treatment, and the appropriateness of institutional disclosures.

07 No $0 $0

The Under Secretary for Health ensures legacy site providers are aware of mitigations needed for patients previously treated at a new electronic health record site and monitors compliance.

08 No $0 $0

The Under Secretary for Health ensures that pharmacist staffing levels are assessed and addressed prior to the implementation of the new electronic health record at additional VA sites.

09 No $0 $0

The Under Secretary for Health evaluates the underlying technical and functional issues resulting in workarounds and educational materials needed to perform pharmacy-related operations within the new electronic health record and takes action as indicated.

Department of Veterans Affairs OIG

United States