Vets Exposed to Incorrect Drug Doses
January 14, 2009
Associated Press

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WASHINGTON - Patients at Veterans Affairs health centers around the country were given incorrect doses
of drugs, had needed treatments delayed and may have been exposed to other medical errors due to software glitches that showed faulty displays of their electronic health records.

The glitches, which began in August and lingered until last month, were not disclosed by the Veterans Affairs Department to patients even though they sometimes involved prolonged infusions of drugs such as heparin, which in excessive doses can be life-threatening, according to internal documents obtained by The Associated Press under the Freedom of Information Act.

There is no evidence that any patient was harmed, even as the VA says it continues to review the situation. But the issue is more pressing as the federal government begins promoting universal use of electronic medical records. President George W. Bush has supported the effort and incoming President-elect Barack Obama has made it a top priority, part of an additional $50 billion a year in spending for health IT programs that he has proposed.

The goal of electronic medical records nationwide is to help avert millions of medical mistakes attributed in part to paper systems, such as poorly written prescriptions. But health care experts say the VA's problems illustrate the need for close monitoring.

Veterans groups were also harshly critical, saying the VA's secrecy created a false sense of security.

"It's very serious potentially," said Dr. Jeffrey A. Linder, an assistant professor of medicine at Harvard Medical School who has studied electronic health systems. "There's a lot of hype out there about electronic health records, that there is some unfettered good. It's a big piece of the puzzle, but they're not magic. There is also a potential for unintended consequences."
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.

In a statement late Tuesday, the VA said there were nine reported cases where patients at the VA medical centers in Milwaukee, Durham, N.C., and Marion, Ind., were given incorrect doses, six of them involving heparin drips that were given for up to 11 hours longer than necessary. The other cases involved infusions of either sodium chloride or dextrose mixtures that were prolonged for up to 15 hours past the doctor's prescribed deadline.

The VA 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 http://www.myhealth.va.gov.

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.

Stephen Warren, the VA's acting assistant secretary for information technology, said VA hospitals were able to minimize the consequences because they had several alternative systems in place for nurses to check on a patient's treatment. Alert doctors also reported glitches after noticing that a patient's record looked similar to a previous patient's.
Warren said the VA was confident that its doctors took the proper precautions to avoid any harm to their patients. But he added, "VA believes that veterans are active partners in their health care, and encourages patients to always follow up with their health care teams to ensure that their treatment options meet their understanding and their health care needs."
Veterans groups questioned the VA's decision to keep the problems quiet.

"This is disturbing on a number of levels because of what could have happened," said Veterans of Foreign Wars National Commander Glen Gardner. "Being told that no patients were harmed still does not absolve the VA from its responsibility to forewarn patients that something is amiss. Trust is paramount in doctor-patient relationships, and nothing should ever be allowed to undermine that confidence."

According to interviews and the VA's internal memos, the glitches began after the VA distributed its annual software upgrade last August.

By early October, hospitals began reporting the troubling problems: When doctors pulled up electronic records of different patients within 10 minutes of each other to offer treatment advice, the medical information of the first patient sometimes displayed under the second person's name. In some records, a doctor's stop order for intravenous injections also failed to clearly display.

The VA issued several safety alerts to medical centers beginning Oct. 10. It also imposed new safety measures until the glitches were fully corrected in December.

"Patients can ... be at risk for delay in treatment changes or possible medication errors," according to one internal memo dated Oct. 31. "These changes have resulted in reported delays for stopping continuous infusion orders (e.g., stopping IV heparin drips)."

Dr. Bart Harmon, a former Pentagon chief medical information officer who helped coordinate the government's electronic records system from 1997 to 2007, cautioned that the VA's problems could become more common as more hospitals and doctors' offices move toward electronic records.

"This is a classic problem in health care - it's hard to get people to invest in prevention," said Harmon, who now works for Harris Healthcare Solutions, an information technology firm based in Melbourne, Fla. "The money tends to drift to obvious risks that are wrong. But safety checks are a new investment that needs to be maintained."


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