Inappropriate EMR Use Causes At Least Two ED Patients At VA To Die

Problems using the EMR in the emergency department at the Memphis Veterans Affairs facility led to the deaths of two people — and possibly more — according to the VA’s Office of the Inspector General,  iHealthBeat reports.

In one case, a nurse had entered into an EMR that a patient was allergic to aspirin. But the physician bypassed the EMR and instead wrote out a prescription for ketorolac, an anti-inflammatory drug contraindicated for patients with aspirin allergies. The patient went into respiratory and cardiac arrest and died, according to iHealthBeat.

The report also identified another case in which a patient died after doctors failed to treat a patient’s high blood pressure in a timely basis due to incomplete and conflicting progress notes.

In a third case, still under investigation, a patient became comatose and died after being given three separate drugs for back  pain and not being properly monitored for oxygen saturation.  According to the OIG, it’s not yet clear whether the EMR contributed to the patient’s death.

This is not the first time that the OIG has called attention to possible problems in this facility’s ED. The OIG previously reviewed operations in the facility’s ED in 2012, after a complaint alleged that conditions in the ED were putting patients at risk. The facility is still in the process of responding to those recommendations, the agency notes.

Now, it’s entirely possible that this VA facility has problems that go well beyond technology, especially if two separate OIG investigations found problems there.

But it’s also possible that the staff simply needs better training on the EMR, something that is quite fixable if the leadership decides to  move forward.

That being said, if the DoD and VA do move once again toward a joint EMR, the odds of bugs in the system emerging is great. Let’s hope that the movement toward building the iEHR, patient harm doesn’t increase.

About the author

Anne Zieger

Anne Zieger

Anne Zieger is a healthcare journalist who has written about the industry for 30 years. Her work has appeared in all of the leading healthcare industry publications, and she's served as editor in chief of several healthcare B2B sites.

1 Comment

  • Wouldn’t the same happen if it were a paper chart? An electronic medical record cannot prevent negligence.

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