Scheduling Error of the New Electronic Health Record and Inadequate Mental Health Care at the VA Central Ohio Healthcare System in Columbus Contributed to a Patient Death

The VA Office of Inspector General (OIG) reviewed concerns related to the care of a patient who died by accidental overdose approximately seven weeks after a missed appointment at the VA Central Ohio Healthcare System in Columbus (facility). The OIG evaluated staff’s failure to conduct minimum scheduling efforts due to an error in new electronic health record (EHR) functioning. The OIG reviewed the adequacy of mental health evaluations of the patient, supervision of a psychologist, caring communications management, and an internal review of the patient’s care.

The OIG found that due to the EHR system error, the patient’s missed appointment was not routed to a queue to prompt rescheduling efforts. The OIG determined that, unlike established care standards, for sites using the new EHR, VHA required fewer patient contact attempts following missed mental health appointments. 

The OIG found that the nurse practitioner did not evaluate a request from the patient to restart medication nor obtain a comprehensive mental health history. The psychologist did not thoroughly evaluate or address the patient’s depression and failed to reconcile critical clinical information. The OIG would have expected a supervisory psychologist to identify concerns about the patient’s depression, substance use relapse risk, and suicidal behavior, and ensure follow-up regarding the medication request. 

The OIG found that staff failed to send the patient caring communications after high risk for suicide patient record flag inactivation. Facility leaders did not communicate a root cause analysis Lesson Learned to staff as expected.

The OIG made one recommendation to the Deputy Secretary to monitor new EHR scheduling functionality. The OIG made two recommendations to the Under Secretary for Health to evaluate minimum scheduling effort requirements and establish Lessons Learned guidance. The OIG made two recommendations to the Facility Director to review the patient’s care and Caring Communication Program compliance.