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

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 of the VA Nebraska-Western Iowa Healthcare System. The patient died unexpectedly, and a medical examiner determined that 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 medication management was appropriate. The patient had a complex medical and mental health history, which included acute and chronic pain. Providers documented appropriate assessments and evaluations, and considered the risks of medication, dependency, and side effects. Providers performed medication reconciliations, which included routine reviews of active VA and non-VA medications and the patient’s compliance with his medication regimen. Providers monitored the patient for identified potential adverse medication interactions and performed annual blood chemistries, drug levels, and EKGs. We made no recommendations.