EHR workarounds, poor documentation cause deaths at Memphis VA

The inadequate use of the Memphis VA Medical Center's EHR led to the deaths of at least two patients in its emergency department (ED), according to a new report by the Department of Veteran's Affairs' Office of Inspector General (OIG).

The OIG, which conducted its inspection after receiving a complaint of three patient deaths, found that in one case a nurse had inputted into the EHR the fact that the patient had an allergy to aspirin, but that the physician bypassed the EHR and hand-wrote an order for an anti-inflammatory drug that is contraindicated for aspirin. Had the physician order been inputted into the EHR, pursuant to hospital policy, a drug alert would have automatically been generated.

The patient went into full cardiac and respiratory arrest soon after receiving the drug and died eight days after the family agreed to take him off life support. In another case, incomplete and conflicting EHR progress notes caused a delay in the treatment of a patient's high blood pressure. He was later found unresponsive and died the next day.

A third patient died after receiving multiple sedating drugs via handwritten orders and then not being properly monitored for oxygen saturation. It was unclear whether the failure to use the EHR contributed to his death.  

This is not the first time that the OIG has uncovered inadequate patient care in the Memphis VA's emergency department.

The VA is one of the largest users of EHRs but evidently is running into some trouble with its use. A recent investigation revealed that the VA is also one of the largest violators of HIPAA's privacy rule, with incidents ranging from snooping in the EHRs to identity and prescription theft.

To learn more:
- read the OIG report

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