VA hospital deaths partly due to not following EHR policies

The deaths of three patients in a Veterans Administration (VA) hospital in Memphis last year were due to negligence by hospital staff and related to improperly following the facility’s EHR policies, according to a Veterans Administration Inspector General report.

An anonymous complaint describing potential inadequate care incidents at the Memphis VA Medical Center’s 22-bed emergency department (ED) led to the VA Office of the Inspector General's review of committee minutes, relevant documents and the EHRs of the patients, and largely substantiated the claims, finding physicians missing nurse notes and EHR alerts, and a poor ED design leaving some patients only partly monitored.

One patient confirmed an aspirin allergy with a nurse upon arrival, but the physician reviewing the patient three hours later hand-wrote on paper an order for a drug containing aspirin, missing an alert of the contraindication and bypassing the medical center’s policy of digital documentation.

The OIG found that ED staff also missed an alert or an alert never went off for another patient who received a combination of narcotics, sedatives and tranquilizers, developed low oxygen levels, became unresponsive and died in a coma 13 days later.

Internal investigations of the two doctors involved in the three incidents cleared them of wrongdoing.

A statement from the VA said it has already taken a number of steps to address the issues raised by the report. “Memphis VA takes this issue very seriously, and has acted to address and correct issues directly contributing to the deaths, and continues to take steps to improve the care provided in our Emergency Department,” the statement noted.