VA reviewing medications at Lincoln Community Based Outpatient Clinic

Healthcare Inspection
Review of a Patient’s Medication Management
Lincoln Community Based Outpatient Clinic Lincoln, Nebraska
August 10, 2012

Executive Summary
The VA Office of Inspector General Office of Healthcare Inspections conducted a review of the medication management provided for a patient who received health care and prescriptions at the Lincoln Community Based Outpatient Clinic (CBOC) of the VA Nebraska-Western Iowa Healthcare System. The patient died unexpectedly, and a medical examiner determined the patient’s cause of death was accidental multidrug toxicity. The purpose of this review was to determine if the patient received appropriate medication management.

The patient had a complex medical and mental health history, which included acute and chronic pain. He was well known to CBOC staff; from 2004 through February 2012, he received MH, primary care, and/or pharmacy services at least every 30 days at the CBOC.

A psychiatrist treated the patient and prescribed medications to address his mental health needs. A physician assistant treated the patient and prescribed medications to address his other acute and chronic conditions. CBOC providers prescribed a number of medications that had the potential for adverse interactions. The patient’s medication regimen remained essentially the same for several years prior to his death. Providers performed medication reconciliations, (reviews of active VA and non-VA medications), and monitored the patient’s compliance with his medication regimen.

Providers, pharmacists, and pharmacy software identified potential adverse medication interactions (low blood pressure, elevated potassium, and electrocardiogram abnormalities). Providers monitored these potential adverse medication interactions by annual blood chemistries, drug levels, and electrocardiograms. Mental Health providers conducted assessments at an appropriate frequency, referred the patient to pain management clinic services, and monitored his prescribed opioid use closely. CBOC providers managed the patient’s medication management appropriately. We made no recommendations. read report here