Drug Interactions Related to a Patient Death, Marion VA Medical Center in Illinois

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the Marion VA Medical Center in Illinois (facility) to review an allegation that a patient died due to complications from high cholesterol. The OIG substantiated that high cholesterol contributed to the patient’s death; however, the death certificate indicated that the primary cause of death was accidental acute multi-drug intoxication. The psychiatrist and staff failed to document providing the patient with education during a telephone encounter regarding potential side effects or adverse drug-drug interactions of medication changes. Contrary to clinical guidance, the psychiatrist prescribed long-term benzodiazepine use for a patient diagnosed with posttraumatic stress disorder. The psychiatrist also failed to address the patient’s two negative urine drug screens for a prescribed medication, and failed to address a positive urine drug screen for cannabis. Due to COVID-19, the facility failed to launch the Psychotropic Drug Safety Initiative Phase Four Plan. The primary care provider did not comply with facility policy by failing to enter a return-to-clinic order following an appointment but could not determine if this affected the patient. Primary care and behaviorial health staff did not comply with facility policy to telephone the patient or send a letter after the patient missed appointments. The OIG made five recommendations related to ensuring behavioral health staff provide and document patient education regarding possible side effects of medications and adverse drug-drug interactions; timely communicating test results; monitoring implementation of Phase Four of the Psychotropic Drug Safety Initiative; ensuring primary care staff comply with entering return-to-clinic orders; and ensuring primary care and behavioral health staff document contacts, attempted contacts, and letters sent when a patient misses an appointment.