Veterans exposed to incorrect drug doses

By: By HOPE YEN, Associated Press Writer
By: By HOPE YEN, Associated Press Writer

WASHINGTON (AP) - 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

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

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

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

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

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

AP Medical Writer Lauran Neergaard contributed to this report.

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(Copyright 2009 by The Associated Press. All Rights Reserved.)

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