VA and Defense Health Care: Increased Risk of Medication Errors  
for Shared Patients (27-SEP-02, GAO-02-1017).			 
                                                                 
Adverse drug events, which include adverse drug reactions and	 
preventable medication errors, have gained national attention in 
recent years. The risk of medication errors is an important issue
for the Department of Veterans Affairs (VA) and the Department of
Defense (DOD) because their large beneficiary populations receive
many prescriptions. Each agency has recognized the significance  
of medication errors and has instituted practices to reduce them,
such as making patients' medical records more accessible to	 
providers and performing checks for drug interactions. Although  
each agency designed safeguards to protect its own patients,	 
certain VA and DOD patients receive medication from both	 
agencies. Shared patients face an increased risk of medication	 
errors. Joint (DOD and VA) venture sites with inpatient 	 
facilities provide services to shared inpatients in the same	 
manner as they do for their own beneficiaries, that is, 	 
medications are ordered using the facility's guidelines and	 
filled through the inpatient pharmacy at that facility. Gaps in  
safeguards result primarily from VA's and DOD's separate,	 
uncoordinated information and formulary systems. Joint venture	 
sites have taken steps to address some of these safety gaps. For 
instance, all sites have made patient information more accessible
by providing additional, although incomplete, access to the other
agency's patient information system.				 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-02-1017					        
    ACCNO:   A05178						        
  TITLE:     VA and Defense Health Care: Increased Risk of Medication 
Errors for Shared Patients					 
     DATE:   09/27/2002 
  SUBJECT:   Drugs						 
	     Health hazards					 
	     Interagency relations				 
	     Joint ventures					 
	     Medical information systems			 
	     Medical records					 
	     Patient care services				 
	     Pharmaceutical industry				 
	     DOD Composite Health Care System			 
	     DOD Pharmacy Data Transaction Service		 
	     VA Computerized Patient Record System		 
	     VA Veterans Integrated Service Network		 

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GAO-02-1017

Report to Chairman, Subcommittee on Defense, Committee on Appropriations,
U. S. Senate

United States General Accounting Office

GAO

September 2002 VA AND DEFENSE HEALTH CARE

Increased Risk of Medication Errors for Shared Patients

GAO- 02- 1017

Page i GAO- 02- 1017 Increased Risk of Medication Errors Letter 1 Results
in Brief 2 Background 4 Shared Patients Obtain Inpatient Drugs from the
Treating Agency

but Generally Return to Home Agency for Outpatient Drugs 13 Shared
Patients Experience Gaps in Medication Safety Measures 14 Safety Gaps
Remain Despite Efforts to Address Them 20 Conclusions 22 Recommendations
For Executive Action 23 Agency Comments and Our Evaluation 23 Appendix I
Comments from the Department of Veterans Affairs 27

Appendix II Comments from the Department of Defense 31

Appendix III GAO Contacts and Staff Acknowledgments 33

Table

Table 1: Description of Joint Venture Sites and Services as of August 2002
6 Figures

Figure 1: Safeguards in Process Typically Used by VA and DOD to Provide
Medications to Their Own Beneficiaries 8 Figure 2: Gaps in Medication
Safeguards for Shared Patients 15 Contents

Page ii GAO- 02- 1017 Increased Risk of Medication Errors Abbreviations

ADE adverse drug event ASHP American Society of Health- System Pharmacists
DOD Department of Defense CHCS Composite Health Care System CPOE
computerized provider order entry CPRS Computerized Patient Record System
FHIE Federal Health Information Exchange

GCPR Government Computer- Based Patient Record IOM Institute of Medicine
IHS Indian Health Service ISMP Institute for Safe Medication Practices
JCAHO Joint Commission on Accreditation of Healthcare

Organizations MTF military treatment facility PDTS Pharmacy Data
Transaction Service P& T pharmacy and therapeutics

VA Department of Veterans Affairs

Page 1 GAO- 02- 1017 Increased Risk of Medication Errors

September 27, 2002 The Honorable Daniel K. Inouye Chairman Subcommittee on
Defense Committee on Appropriations United States Senate

Dear Mr. Chairman: Adverse drug events (ADE), which include adverse drug
reactions and preventable medication errors, have gained national
attention in recent years. The risk of medication errors is an important
issue for the Department of Veterans Affairs (VA) and the Department of
Defense (DOD), in part because their large beneficiary populations receive
many prescriptions* in fiscal year 2000, 86 million and 66 million,
respectively. Each agency has recognized the significance of medication
errors and has instituted practices to reduce them, such as making
patients* medical records more accessible to providers and performing
checks for drug interactions. Although each agency designed safeguards to
protect its own patients, certain VA and DOD patients receive medications
from both agencies* either because they are eligible for care under both
systems or because they are referred from one agency to the other under
VA- DOD health resources sharing agreements. Preventing medication errors
for these shared patients presents an additional challenge.

VA and DOD estimate that about 800,000 beneficiaries are dually eligible
for care from VA and DOD and an unknown number of additional beneficiaries
receive care through sharing agreements. 1 Concerned about the
effectiveness of medication safeguards for shared patients, you asked us
to determine (1) from which agency shared patients obtain

medications, (2) whether gaps exist in medication safeguards for shared
patients, and (3) if gaps exist, how they are being addressed. 1 VA and
DOD could not provide us with the number of beneficiaries receiving care
under

sharing agreements. However, in our 2000 report, VA and Defense Health
Care: Evolving Health Care Systems Require Rethinking of Resource Sharing
Strategies (GAO/ HEHS- 00- 52, May 17, 2000), six joint venture sites*
sites where VA and DOD have

pooled resources to capitalize on existing facilities or to build new
ones* reported about 360,000 episodes of care under sharing agreements for
fiscal year 1998.

United States General Accounting Office Washington, DC 20548

Page 2 GAO- 02- 1017 Increased Risk of Medication Errors

To conduct our work, we reviewed VA*s and DOD*s processes for providing
outpatient and inpatient medications to shared patients. To focus our
review on locations with large numbers of shared patients, we examined VA
and DOD*s seven joint ventures, which have had experience working together
under sharing agreements. At your request, we conducted an on- site review
of pharmacy operations at the joint venture in Hawaii, where there is an
agreement between Tripler Army Medical Center and the VA Medical and
Regional Office Center. At this site, we observed

how medications are provided to shared patients and evaluated these
processes for gaps in medication safeguards. We also examined medication
error reports and interviewed VA and DOD providers, pharmacists, patient
safety personnel, and information systems personnel. We spoke by telephone
with personnel in similar positions at the six other joint venture sites
to identify procedures used to provide medications to shared patients and
evaluated these procedures for medication safety gaps. We spoke with
personnel at all joint venture sites about their medication safety
programs, but we were not able to identify errors specific to shared
patients because neither VA nor DOD tracks information in this way.

We also spoke with VA and DOD headquarters personnel knowledgeable about
pharmacy, patient safety, formulary, and information technology issues. 2
In addition, we reviewed the literature on medication errors and consulted
experts on patient safety and medication errors from the Joint Commission
on Accreditation of Healthcare Organizations (JCAHO); the Institute for
Safe Medication Practices (ISMP); and the Leapfrog Group for Patient
Safety, a coalition of more than 100 public and private organizations that
provide health care benefits. We conducted our work from February 2002
through September 2002 in accordance with generally accepted government
auditing standards.

Joint venture sites with inpatient facilities provide pharmacy services to
shared inpatients in the same manner as they do for their own
beneficiaries, that is, medications are ordered using the facility*s
guidelines and filled through the inpatient pharmacy at that facility.
Although the process for providing medications to shared outpatients

differs across sites, generally each agency expects its beneficiaries to
use 2 A formulary is a set of drugs that a health care organization
prefers that its physicians prescribe. Results in Brief

Page 3 GAO- 02- 1017 Increased Risk of Medication Errors

its own, separate pharmacy for outpatient prescriptions, even when
prescriptions are ordered by providers from the other agency. At one joint
venture, a single DOD pharmacy provides medications for both VA and DOD
outpatients. However, VA patients obtain only initial, short- term
prescriptions at this DOD pharmacy; longer- term prescriptions and refills
are obtained by mail from VA.

Shared patients face an increased risk of medication errors. Gaps in
safeguards result primarily from VA*s and DOD*s separate, uncoordinated
information and formulary systems. Providers and pharmacists at joint
venture sites generally do not have access to shared patients* complete
health information to aid in making medication decisions because
information in one agency*s electronic health record system is generally
not accessible by the other agency. Also, providers of one agency
generally cannot use computerized provider order entry (CPOE) to order
drugs that are to be dispensed in the other agency*s pharmacy. As a
result, the potential for error is introduced when prescriptions are
handwritten or reentered into the other agency*s pharmacy system.
Moreover, automatic checks for drug allergies and interactions are not
complete for shared patients because medications dispensed by the other
agency will not be included in the check. VA*s and DOD*s separate
formulary systems also complicate providing medications to shared patients
because providers either prescribe from the other agency*s formulary,
which may contain unfamiliar drugs, or prescribe a limited supply of a
drug, which may later be switched to comply with the formulary of the
patient*s home agency. 3 Such switching puts the patient at greater risk
for an adverse drug

reaction. Joint venture sites have taken steps to address some of these
safety gaps. For instance, all sites have made patient information more
accessible by providing additional, although incomplete, access to the
other agency*s patient information system. Some sites have produced
computer- printed, rather than handwritten, prescriptions or developed
practices to collect information on medications that patients are using
from other sources, for instance, those obtained from the other agency. In
addition, some have addressed the problems created by separate formulary
systems by having both agencies represented on the pharmacy and
therapeutics (P& T)

3 *Home agency* is used in this report to refer to the primary agency the
patient relies on for care and *treating agency* for the other agency. For
instance, VA is the home agency for VA patients referred to DOD for care,
and DOD is the treating agency.

Page 4 GAO- 02- 1017 Increased Risk of Medication Errors

committee, the group that makes decisions about drugs included on the
formulary, or by stocking nonformulary drugs used by the other agency.
However, none of these practices fully addresses the safety gaps. In
addition, the use of such practices varies by site.

We are recommending that VA and DOD improve procedures, especially
relating to sharing of electronic information, for patients using both
systems so that they are not at greater risk of medication errors than if
they received their care from only one system. In its comments to our
draft report, VA concurred with all our recommendations. DOD concurred
with our recommendations to develop the capability for VA and DOD
providers to access patient information in both agencies* patient
information systems and to develop comprehensive drug interaction checks
that include both VA- and DOD- provided drugs. DOD also agreed to require
providers to use CPOE for shared patients where it is available. It
disagreed with modifying the current systems as a way of extending this
capability because both agencies have longer- term plans to upgrade or
replace their pharmacy information system modules. However, because of the
time it will take to upgrade or replace the system modules, shared
patients continue to be at risk for medication errors. DOD also said that
it did not concur with establishing a joint P& T committee at each joint
venture site. We recommended the establishment of either a joint P& T
committee or a similar working group, and DOD indicated support for such
working groups.

To encourage the sharing of federal health care resources, the Veterans
Administration and Department of Defense Health Resources Sharing and
Emergency Operations Act authorizes VA medical centers and DOD military
treatment facilities (MTF) to enter into sharing agreements to buy, sell,
and barter medical and support services. 4 Local VA and DOD officials have
identified benefits that have resulted from such sharing, including
increased revenue, enhanced staff proficiency, fuller utilization of staff
and equipment, improved beneficiary access, and reduced cost of services.
5 4 Pub. L. No. 97- 174, 96 Stat. 70 (1982) (codified to 38 U. S. C. S:
8111 (2000)).

5 U. S. General Accounting Office, VA and Defense Health Care: Evolving
Health Care Systems Require Rethinking of Resource Sharing Strategies,
GAO/ HEHS- 00- 52 (Washington, D. C.: May 17, 2000). Background

Page 5 GAO- 02- 1017 Increased Risk of Medication Errors

Seven of these sharing agreements are joint venture agreements, which
involve the sharing of physical space as well as health care services.
These joint ventures range from a single, jointly staffed MTF serving both
VA and

DOD patients* as is the case with Mike O*Callaghan Federal Hospital at
Nellis Air Force Base in Nevada* to more modest sharing in Key West,
Florida, where VA and DOD share a building that houses their separate
outpatient clinics. In addition to physical space, agreements at these
sites usually provide for one agency to refer patients to the other for
inpatient and/ or outpatient care. As table 1 shows, DOD is most often the
host agency, that is, the agency providing the majority of services.

Page 6 GAO- 02- 1017 Increased Risk of Medication Errors

Table 1: Description of Joint Venture Sites and Services as of August 2002
Joint venture Host

agency General description of health care services shared

Alaska Elmendorf Hospital, Elmendorf Air

Force Base Alaska VA Healthcare System and

Regional Office DOD Air Force hospital serves DOD and VA inpatients. Air
Force also

provides certain outpatient specialty care for VA patients. California

David Grant Medical Center, Travis Air Force Base VA Northern California
Health Care

System DOD Air Force hospital at Travis Air

Force Base serves DOD and VA inpatients. Air Force also provides certain
outpatient specialty care for VA patients. VA hospital at Sacramento
provides certain

specialty outpatient care to DOD patients. Florida a Key West Naval Branch
Clinic

VA Community Based Clinic DOD DOD provides outpatient

pharmacy medications to both DOD and VA patients. b Hawaii

Tripler Army Medical Center Honolulu VA Medical and Regional

Office Center DOD Army hospital serves DOD and VA

inpatients. Army also provides certain outpatient specialty care for VA
patients. Nevada

Mike O*Callaghan Federal Hospital, Nellis Air Force Base VA Southern
Nevada Healthcare

System DOD Jointly staffed Air Force hospital

serves DOD and VA inpatients. Hospital also provides certain outpatient
specialty care for both VA and DOD patients.

New Mexico United States Air Force Clinic, Kirtland Air Force Base New
Mexico VA Health Care System

VA VA hospital serves VA and DOD inpatients. VA also provides certain
outpatient specialty care for DOD patients.

Texas William Beaumont Army Medical

Center, Fort Bliss El Paso VA Health Care System

DOD Army hospital serves DOD and VA inpatients. Army also provides certain
outpatient specialty care

for VA patients. a The sharing agreement for these clinics is between the
Naval Hospital Jacksonville and the Miami VA Medical Center. b Pharmacy
services are the primary focus of this sharing agreement, but VA also
provides limited

specialty care to DOD patients. Source: VA and DOD joint venture site
documents and officials.

In addition to referred patients, joint ventures, like other VA and DOD
facilities, share dually eligible patients. Recent changes in VA*s and
DOD*s health care programs have increased both the number of dual
eligibles and the likelihood that they will obtain services from both
systems. The

Page 7 GAO- 02- 1017 Increased Risk of Medication Errors

number of veterans, including all military retirees, eligible for VA
health care was increased in fiscal year 1999 due to removal of statutory
restrictions. 6 In addition, the number of military retirees eligible for
DOD health care increased in 2001 when full eligibility was extended to
retirees age 65 and over. 7 Furthermore, a February 2002 increase in VA*s
copayment for outpatient drugs* from $2 per prescription to $7 per
prescription* has given dual eligibles who receive health care from VA
more incentive to have their prescriptions filled at a DOD pharmacy. 8 The
Institute of Medicine (IOM) raised national awareness of the problem

of medication errors with its 2000 study, To Err is Human: Building a
Safer Health System. 9 As we reported in 2000, there is general agreement
that medication errors are a significant problem, although the actual
magnitude of the problem is uncertain. 10 Researchers and patient safety
advocates have suggested certain measures to reduce the risk of medication
errors, and VA and DOD have incorporated many of these measures as
features of their health care systems. Figure 1 illustrates the typical
process, including safeguards that VA and DOD use to provide medications
to patients. 6 Income restrictions were removed by the Veterans Health
Care Eligibility Reform Act of

1996, Pub. L. No. 104- 262, S: 101, 110 Stat. 3177, 3179 (1996). VA's
implementing regulations are found at 38 C. F. R. S:S: 17. 46, 17.47
(2001). 7 Eligibility was expanded by the Floyd D. Spence National Defense
Authorization Act for Fiscal Year 2001, Pub. L. No. 106- 398, S:S: 711-
712, 114 Stat. 1654, 1654A- 175, 1654A- 176 (2000). Formerly, military
retirees 65 and older were treated on a space- available basis.

8 This copayment is adjusted annually for inflation. 9 IOM estimated that
over 7, 000 people in the United States die each year from medication
errors. Institute of Medicine, To Err is Human: Building a Safer Health
System (Washington, D. C.: National Academy Press, 2000). 10 U. S. General
Accounting Office, Adverse Drug Events: The Magnitude of Health Risk Is
Uncertain Because of Limited Incidence Data, GAO/ HEHS- 00- 21
(Washington, D. C.: Jan. 18, 2000). Medication Errors Pose

Significant Risk

Page 8 GAO- 02- 1017 Increased Risk of Medication Errors

Figure 1: Safeguards in Process Typically Used by VA and DOD to Provide
Medications to Their Own Beneficiaries

a At most DOD MTFs, DOD providers lack the capability to electronically
order medications for inpatients. Source: VA and DOD headquarters
officials and joint venture site documents and officials.

Page 9 GAO- 02- 1017 Increased Risk of Medication Errors

Medication safety experts have identified the following factors that can
contribute to reducing medication errors.

According to experts from organizations such as the American Society of
Health- System Pharmacists (ASHP) and IOM, access to patient medical
information is important to both providers and pharmacists in reducing
medication errors. A study of adverse drug events conducted by Brigham and
Women*s Hospital found that the inaccessibility of patient information*
such as information on the patient*s condition, results of

laboratory tests, and current medications* was a leading cause of
prescribing errors. 11 The ASHP guidelines for preventing hospital
medication errors state that prescribers should evaluate the patient*s
total status and review all existing drug therapy before prescribing new
or additional medications. They also recommend that pharmacists and others
responsible for processing drug orders should have routine access to
appropriate clinical patient information* including medication and allergy
profiles, diagnoses, and laboratory results* to help evaluate the
appropriateness and efficacy of medication orders. One way to provide this
ready access is a computerized medical record. A computerized medical
record can improve health care delivery by providing medical personnel
with better data access, faster data retrieval, and more versatility in
data display than available with a paper record. 12 Both VA and DOD are in
the process of transitioning from paper- based to

electronic systems for recording and accessing patient health information.
VA*s system, the Computerized Patient Record System (CPRS), captures a
wide range of patient information, including progress notes, vital
statistics, laboratory results, medications, drug allergies, and
radiological and catheterization images. DOD*s system, the Composite
Health Care System

(CHCS), captures similar, but less extensive, patient information. For 11
Lucian L. Leape and others. *Systems Analysis of Adverse Drug Events,* The
Journal of the American Medical Association, vol. 274, no. 1 (1995). 12 U.
S. General Accounting Office, Medical ADP Systems: Automated Medical
Records Hold Promise to Improve Patient Care, GAO/ IMTEC- 91- 5
(Washington, D. C.: Jan. 22, 1991), and

Institute of Medicine, The Computer- Based Patient Record: An Essential
Technology for Health Care (Washington, D. C.: National Academy Press,
1997). Accessible Patient Medical

Information

Page 10 GAO- 02- 1017 Increased Risk of Medication Errors

example, CHCS cannot capture or store progress notes or electronic images.
13 JCAHO standards for hospitals and ambulatory health organizations

require that organizations maintain formularies and direct that they must
consider the potential for medication errors as a criterion for selecting
drugs that will be stocked. 14 Although frequently considered a mechanism
for controlling costs, patient safety experts maintain that formulary
systems can also optimize therapeutic outcomes and facilitate medication
safety. 15 According to IOM, a formulary system can help reduce adverse
drug events because the drugs selected for the formulary are evaluated by
knowledgeable experts and chosen based on their relative therapeutic

merits and safety. 16 In addition, formularies limit unneeded variety in
drug use* a practice supported by ISMP and the Institute for Healthcare
Improvement* and assist in educating prescribers on safe and appropriate
use of formulary drugs.

Both VA and DOD have formulary systems. VA*s national formulary consists
of about 1,200 pharmacy items, including over 1,000 drugs, and each of
VA*s 21 regional Veterans Integrated Service Networks can augment the
national formulary. DOD*s Basic Core Formulary consists of about 165
drugs, and an MTF can add other drugs based on the clinical services and
scope of care provided by that facility. 17 Both agencies also have
approval processes for prescribers to obtain nonformulary drugs for their
patients when medically necessary. As part of their ordering systems,

13 DOD is developing an enhanced health information system, CHCS II.
Starting this year, this system will be deployed in installments over the
next 6 years and will allow for capturing additional patient information
and provide more capabilities, for instance, more clinical decision
support, than CHCS currently has.

14 JCAHO Sentinel Event Alert, Issue 19, May 2001. 15 By formulary system,
we mean not only the list of preferred drugs but also the associated
processes used by organizations to select safe and efficacious drugs and
to monitor and guide their use.

16 Institute of Medicine, Description and Analysis of the VA National
Formulary (Washington, D. C.: National Academy Press, 2000). 17 In the
National Defense Authorization Act for Fiscal Year 2000, Congress required
DOD to implement a uniform drug formulary by October 2000, applicable to
military pharmacies, retail pharmacies, and DOD's mail order pharmacy
(Pub. L. No. 106- 65 S: 701 (a)( 1), (2)( A), 113 Stat. 512, 677 (2000)
(codified to 10 U. S. C. 1074g (a)( 1), (2)( A) (2000)). DOD issued a
proposed rule to establish a uniform formulary in April 2002, but this
rule has not been finalized (67 Fed. Reg. 17948 (2002)). Formulary Systems

Page 11 GAO- 02- 1017 Increased Risk of Medication Errors

some VA and DOD facilities have also developed electronic decisionmaking
support related to their formularies, such as prompts to remind physicians
to order specific laboratory tests prior to administering certain drugs or
alerts related to the safe use of certain drugs.

CPOE systems can reduce medication errors by eliminating legibility
problems of handwritten orders and providing clinical decision- making
support by sending alerts and instantaneous reminders directly to
providers as orders are being placed. 18 For instance, as providers enter
a medication order, they can be given a potential range of doses for
medications ordered, alerted to relevant laboratory results, and prompted
to verify which medication is being ordered when the drug sounds or looks
like another drug on the formulary. Studies have shown computerized
provider ordering reduced medication errors by 55 percent to 86 percent.
19 In light of this evidence, the Leapfrog Group for Patient

Safety adopted computerized provider order entry as one of its initial
safety standards. ISMP has also emphasized the need to take advantage of
electronic ordering technology, calling for the elimination of handwritten

prescriptions nationwide by 2003. VA and DOD acknowledge the safety
benefits of providers electronically ordering medications, and both CPRS
and CHCS (for outpatient prescriptions only at most locations) have this
capability. 20 VA established a goal in its 2002 Network Performance Plan
for 95 percent use of CPOE (both inpatient and outpatient) by 2002, with
100 percent use planned for 2004. 21 While DOD officials told us that CPOE
is encouraged and widely utilized, DOD has no written policy or goals
related to its use.

18 CPOE allows direct entry of medication orders by a prescriber into a
system that electronically transmits these orders to the pharmacy for
filling. 19 David W. Bates and others, *Effect of Computerized Physician
Order Entry and a Team Intervention on Prevention of Serious Medication
Errors,* The Journal of the American Medical Association, vol. 280, no. 15
(1998), and David W. Bates and others, *The Impact of Computerized
Physician Order Entry on Medication Error Prevention,* The Journal of the
American Medical Informatics Association, vol. 6, no. 4 (1999).

20 DOD is evaluating a new pharmacy package that would include inpatient
ordering capability; however, officials were unable to provide us with an
expected implementation date.

21 Chemotherapy and total parenteral nutrition are excepted for inpatient
ordering; narcotics, chemotherapy, and clinic- stocked items (such as
immunizations) are excepted for outpatient ordering. Computerized Provider
Order

Entry

Page 12 GAO- 02- 1017 Increased Risk of Medication Errors

Both VA*s and DOD*s electronic ordering systems perform automatic checks
for potential adverse reactions due to drug allergies and interactions.
VA*s CPRS performs checks for drug allergies and interactions between all
medications ordered and dispensed by a VA facility, including those sent
from VA*s mail order center. Although medications dispensed for the same
patient at another VA facility are generally not included in the check, VA
officials told us that they are exploring methods to broaden their drug
interaction capability. 22 DOD*s system for drug interaction checking is
more comprehensive than VA*s system. CHCS checks for drug allergies and
interactions between drugs prescribed or dispensed at the MTF, and DOD*s
Pharmacy Data Transaction Service (PDTS) aggregates information from CHCS
with other

points of service* other MTFs, network pharmacies, and DOD*s mail order
pharmacy* to perform a complete drug interaction check. 23 Automatic
electronic checks for drug interactions, commonly available in

retail drug stores, have been shown to greatly minimize medication errors.
24 For example, one study found that an automated review of prescriptions
written for 23,269 elderly patients produced 43, 007 alerts warning about
potential medication problems* 24,266 of which recommended a change in
drug or dosage. 25 Professional groups such as ASHP and ISMP have also
acknowledged the value of these systems.

22 VA officials told us that about 14 percent of VA patients have
prescriptions filled at more than one VA facility. Although VA providers
have the ability to remotely view patients* records in other facilities,
this systemwide information is not included in automatic drug checks.

23 Although DOD lacks computerized provider order entry for inpatients at
most locations, this automatic check occurs when inpatient medication
orders are entered into CHCS by pharmacy staff.

24 Such services are often provided by pharmacy benefits managers,
organizations that manage the prescription drug benefit on behalf of the
benefit sponsor, which may be a health plan, a health maintenance
organization, a union, or an employer.

25 Mark Monane and others, *Improving Prescribing Patterns for the Elderly
Through an Online Drug Utilization Review Intervention: a system linking
the physician, pharmacist, and computer,* The Journal of the American
Medical Association, vol. 280, no. 14 (1998), p. 1249( 1). Automatic
Checks for Drug Interactions and Allergies

Page 13 GAO- 02- 1017 Increased Risk of Medication Errors

At the six joint venture sites where inpatient services are provided, all
patients referred for inpatient care receive medications from the
inpatient facility providing the care. 26 Processes used to provide and
record

inpatient medications to referred patients are the same as those used for
the host agency*s own beneficiaries. Inpatient medications are ordered
using the host facility*s formulary guidelines and filled through the
inpatient pharmacy. Initial supplies of discharge medications (usually 30
days or less) are also typically provided, although patients are expected
to return to their home agency pharmacy for longer- term supplies.

In contrast, the process for providing medications to shared outpatients
differs across sites. At six of the joint venture sites, each agency
maintains a separate outpatient pharmacy. As a general rule, each agency
expects its beneficiaries to use its pharmacy for outpatient
prescriptions, even when providers from the other agency order the
prescription. For instance, in Hawaii, both the Tripler Army Medical
Center and the VA outpatient clinic next door maintain outpatient
pharmacies. VA patients who are referred to

Tripler for outpatient specialty care are expected to return to the VA
clinic pharmacy to have their prescriptions filled. Even though this is
the general rule at most sites, we noted that exceptions occur. For
instance, at David Grant Medical Center on Travis Air Force Base, DOD
supplies oncology medications to VA patients. Another exception is that
all joint venture inpatient facilities provide weekend and after- hours
emergency room care to patients of the other agency and, generally,
medications are also supplied if needed. In contrast to the general rule,
at the DOD facility in El Paso, referred VA patients are not expected to
return to their home agency for their initial prescriptions but rather are
allowed to obtain an initial

supply of drugs from the DOD pharmacy. Subsequent prescriptions for these
patients (renewals or refills) must be filled by their VA pharmacy.

At the seventh site, Key West, only DOD maintains a pharmacy. It serves
both VA and DOD patients. However, VA patients receive only initial,
short- term prescriptions (up to 30 days) from this DOD pharmacy and
obtain longer- term prescriptions and refills via mail from the VA Medical
Center in Miami. 27 26 Neither agency has an inpatient facility at Key
West. 27 Homeless veterans in Key West obtain all their medications
through the DOD pharmacy. Shared Patients Obtain Inpatient

Drugs from the Treating Agency but Generally Return to Home Agency for
Outpatient Drugs

Page 14 GAO- 02- 1017 Increased Risk of Medication Errors

VA*s and DOD*s separate, uncoordinated information and formulary systems
result in gaps in medication safeguards for shared inpatients and
outpatients. Lacking coordinated information systems, providers and
pharmacists at joint venture sites often cannot access shared patients*
complete health information, including prescribed medications, nor can
providers from one agency use electronic ordering to prescribe drugs that
are to be dispensed by the other agency*s pharmacy. Because information
systems are uncoordinated, checks for drug allergies and interactions for
shared patients are based on incomplete information. In addition, separate
formulary systems introduce complications for shared patients because

providers must either prescribe from the other agency*s formulary, which
may contain drugs unfamiliar to providers, or prescribe a limited supply
of a drug, which may later be switched to comply with the formulary of the
patient*s home agency. These gaps are illustrated in figure 2. Shared
Patients Experience Gaps in Medication Safety

Measures

Page 15 GAO- 02- 1017 Increased Risk of Medication Errors

Figure 2: Gaps in Medication Safeguards for Shared Patients

Note: This figure depicts the general process for shared inpatients and
outpatients. However, an additional gap exists for shared inpatients that
is not illustrated in the figure. Shared patients who are taking
medications at the time of admission may have those drugs switched to
comply with the agency*s formulary at the inpatient facility. Source: VA
and DOD joint venture site documents and officials.

Page 16 GAO- 02- 1017 Increased Risk of Medication Errors

Ready access to pertinent clinical information is an important feature of
medication safety; while VA*s and DOD*s patient information systems are
capable of serving this function for each agency*s own beneficiaries, gaps
exist for shared patients. VA and DOD providers and pharmacists have

ready access to health records of their own beneficiaries, largely through
CPRS and CHCS, respectively. However, when agencies refer patients for
care, the treating agency*s providers and pharmacists have incomplete
access to patients* health and medication information. Although referrals
will usually be accompanied by some explanation of patients* medical

conditions, the bulk of their electronic health and medication
information, which resides in the health information system of their home
agency, will often not be available to providers and pharmacists in the
agency where they are referred for care. Access for pharmacists and
treating providers to patient information in the referring agency*s
information system varies by location. For example, at four joint venture
sites, pharmacists filling

prescriptions for shared patients have no access to the other agency*s
patient information system. At another site, pharmacy access is
restricted* at Tripler Army Medical Center in Hawaii, access to VA*s CPRS
is available in the inpatient pharmacy, but only one pharmacist has
access. Providers at a few facilities have broader access. For example, at
the David Grant Medical Center at Travis Air Force Base in northern
California, CPRS is installed on every network computer that has CHCS, and
providers in certain departments have been granted CPRS access.

VA and DOD pharmacists and providers we spoke with noted that lack of
relevant patient health information could be a problem for shared
patients. One example given to us was a VA provider treating a dual-
eligible patient for diabetes. Certain drugs cannot be safely prescribed
for diabetics

without monitoring through laboratory tests. If the patient receives care
from a VA physician but has prescriptions filled at a DOD pharmacy, the
pharmacist would be unable to access the patient*s medical record to
review these laboratory results. 28 Without this access, the pharmacist
must call VA to ensure these laboratory values are within normal limits.
In addition, pharmacy personnel at Tripler in Hawaii, where a single
inpatient pharmacist has CPRS access, told us that additional pharmacists
need CPRS access to facilitate after- hours medication needs of VA
patients when this pharmacist is unavailable. 28 While physicians have
initial responsibility for making drug decisions, pharmacists also

play a role in ensuring the safety of medication orders. Providers and
Pharmacists

Have Incomplete Access to Health and Medication Information on Shared
Patients

Page 17 GAO- 02- 1017 Increased Risk of Medication Errors

Computerized provider ordering of medications increases safety by
assisting with medication decisions, providing alerts for drug
interactions and allergies, and obviating handwriting legibility and
transcription

problems. However, prescriptions for shared patients are less likely to be
ordered electronically by providers. Although both VA and DOD providers
have outpatient electronic ordering capabilities when prescriptions are
dispensed at their own pharmacies, patients referred from one agency to
the other for care are typically expected to return to their home pharmacy

to get prescriptions filled. 29 With the exception of DOD providers in
Hawaii, none of the joint venture sites have the capability for providers
to electronically order medications through their own computer systems for
drugs that are to be dispensed by the other agency*s pharmacy, nor do they
typically have access to the other agency*s electronic ordering systems to
issue medication orders. Consequently, providers either handwrite
medication orders for shared patients or give them printed copies that
must be retyped into the patients* home agency*s pharmacy system. Both
situations introduce risks unique to shared patients.

We also found situations where providers had the capability to avoid
handwriting prescriptions but continued to handwrite them. In Key West,
for example, where all drugs are dispensed from the DOD pharmacy, VA
providers have access to DOD*s electronic ordering system, CHCS; but, for
the most part, they handwrite prescriptions. These providers record
patient care and medications in VA*s CPRS, and if they were to
electronically order medications, it would necessitate entry into a second

system. They told us that using CHCS was slow and cumbersome, and ordering
the medications using it took too much time. 30 A VA provider in Hawaii
told us that, for these same reasons, providers sometimes handwrote
prescriptions for dual eligibles to have filled at the DOD pharmacy when
only one or two medications were being ordered.

Finally, although VA patients benefit when providers electronically order
medications in VA hospitals, they generally lose this benefit when
referred to DOD hospitals. Providers in VA hospitals have electronic
ordering capability for inpatient medications, but this capability is not
generally 29 Dual eligibles face a similar situation when they use VA
providers but have their

prescriptions filled by DOD or vice- versa. 30 In a demonstration of CHCS
and CPRS, we observed that CPRS was more user- friendly. Navigating the
system was easier because, unlike CHCS, which requires most commands to be
typed in, most CPRS commands are selected with a mouse. Providers
Generally

Cannot Electronically Prescribe Drugs for Shared Patients

Page 18 GAO- 02- 1017 Increased Risk of Medication Errors

available in DOD hospitals. VA patients referred to DOD hospitals, like
DOD*s own beneficiaries, usually have their prescriptions handwritten by
the provider, and then manually entered into CHCS by pharmacy personnel.
Thus, these patients are subjected to the risks associated with
handwritten prescriptions, such as illegible orders and transcription

errors. Shared patients also do not get the full benefit of VA*s and DOD*s
automatic checks for drug allergies and interactions. VA and DOD patients
who receive all their medications through only one health care system will
have comprehensive medication histories stored in either CPRS or CHCS (in
conjunction with PDTS). When the medication is ordered, CPRS or CHCS/ PDTS
will perform automatic checks for drug allergies and interactions.
However, if patients are taking medications obtained from both agencies,
neither agency*s record of patient medications is complete

at any joint venture site. Thus, when interaction checks are done, they
will be incomplete for shared patients because the checks are restricted
to the information available within each system. Likewise, providers may
be

unaware of drug allergies. For example, when a patient who routinely gets
health care at the VA clinic in El Paso is referred to the Army Medical
Center for outpatient specialty care, the DOD pharmacy will fill a
prescription for up to 30 days of medications. However, when the pharmacy
performs its automatic checks, drug allergies may not be detected because
information on drug allergies is likely to be in VA*s CPRS where the bulk
of the patient*s clinical information is stored, not in CHCS/ PDTS where
the drug check will occur. In its interim report, the President*s Task
Force to Improve Health Care Delivery for Our Nation*s Veterans stated
that the instances of adverse drug events might be substantially reduced
for shared patients through use of a comprehensive screening tool like
PDTS and plans further analysis in this area for its final report. 31
Because VA and DOD each has its own formulary system, providers who

treat referred patients sometimes prescribe from the referring agency*s
formulary and sometimes from their own facility*s formulary, depending on
where the prescription will be filled. Unless the prescribed drug is

31 President*s Task Force To Improve Health Care Delivery For Our Nation*s
Veterans Interim Report, July 2002. Incomplete Record of

Patient Medications Hinders Automatic Checks for Drug Interactions and
Allergies

Uncoordinated Formulary Systems Also Introduce Risks

Page 19 GAO- 02- 1017 Increased Risk of Medication Errors

common to both formularies, each situation limits the medication safety
benefits of a formulary system, such as increased provider familiarity
with drugs prescribed and the added safety net provided by clinical
decision

support. The President*s Task Force to Improve Health Care Delivery for
Our Nation*s Veterans noted that a joint VA/ DOD formulary could combine
the clinical expertise of both VA and DOD and improve patient safety.

Providers who use the other agency*s formulary in prescribing for shared
patients and find that the drug they would normally prescribe is not
listed are disadvantaged in several ways. First, according to formulary
system principles endorsed by the American Medical Association, ASHP, and

others, one characteristic of a formulary system should be that the
pharmacy and therapeutics committee educates providers about drugs on the
formulary. A senior official from ISMP told us that provider drug
knowledge is also reinforced by a formulary system because formularies
limit the number of drugs providers need to be knowledgeable about.
Consequently, providers should be less likely to make mistakes in drug
selection or dosage when prescribing formulary drugs. Second, when
prescribing a drug that is not on their formulary, providers may lose the
clinical support capabilities that may be built into their agency*s CPOE
system. For example, the medication error prevention committee at Tripler
in Hawaii evaluates Tripler*s formulary drugs for safety problems and
designs safeguards into CHCS, such as distinctive lettering to alert
providers to drug names that look alike or sound alike. However, DOD
providers typically try to prescribe for VA outpatients using VA*s
formulary. Consequently, this safeguard is lost to the shared patient.

Providers usually prescribe from their own facility*s formulary for a
referred patient if the prescription is to be filled at their facility*s
pharmacy. For instance, at all joint venture sites, referred inpatients
receive short- term supplies of discharge medications at the host
facility*s pharmacy. If patients need longer- term supplies of medications
or refills, they typically are expected to return to their home pharmacy.
This situation can also put patients at risk if the original medication is
not on the formulary at their home pharmacy. For instance, in Key West, VA
physicians write VA patients two different prescriptions: one for their
initial supply to be filled at the joint venture*s DOD pharmacy and a
second for a longer- term supply that is mailed from the VA Medical Center
in Miami. One VA physician told us that when a VA formulary drug he wants
to prescribe is not on the DOD formulary, he prescribes an equivalent drug
carried by the DOD pharmacy for the short term and orders the VA formulary
drug from Miami to use on a long- term basis. Experts agree that such
interchanging of drugs in a therapeutic class may

Page 20 GAO- 02- 1017 Increased Risk of Medication Errors

sometimes cause problems because differences in individual physiology make
some people react differently to a very similar therapeutic agent.
Although such interchange is an accepted practice in formulary systems,
when physicians are able to avoid switching drugs, they reduce the risk
that an adverse reaction will occur.

Recognizing these risks for shared patients, joint venture facilities have
undertaken efforts intended to address these safety gaps. However, none of
these efforts fully solve the problems that exist, nor are they all used
at any site.

All joint venture sites have taken steps to increase access to patient
information. For example, at Tripler in Hawaii, VA and DOD recently added
VA*s CPRS to computers in the DOD hospital so that VA physicians
monitoring the care of VA inpatients would have electronic access to
patients* VA health records. However, at the time of our visit, most DOD
physicians were unaware that the capability to access CPRS existed, and
DOD officials at Tripler had no plans to promote its use or to provide
training. Similarly, some physicians at all other joint ventures have
access to both systems; but, as in Hawaii, this access is generally
limited in the number of computers that have this capability and the
number of providers who have been authorized to use it. For instance,
access to both systems is available at some locations in the Mike
O*Callaghan Federal Hospital in Nevada, but VA pharmacy officials at the
VA outpatient clinic in this joint venture told us that the lack of such
access in the clinic presented a major problem. They told us that not
having access to such

patient information as test results and physician notes made it difficult
for them to research questions about patients* medications. Only two sites
have pharmacies with access to the other agency*s patient information
system; access is very limited at one of those sites* at Tripler, only one
pharmacist has been authorized to use CPRS. Furthermore, medical personnel
who had access told us that its use is hindered by their lack of
familiarity with the other agency*s system and by the difficulties of
accessing separate, dissimilar systems.

Recognizing the increased risks associated with handwriting prescriptions
rather than using CPOE, two joint venture sites have devised ways to
minimize this risk for shared patients. In Hawaii, VA providers have
worked out an agreement with the DOD pharmacy that they will provide dual
beneficiaries a computer- printed copy of the electronic order, called an
*action profile,* which the pharmacy will accept in lieu of a

handwritten order. In Hawaii* at the time of our visit* and northern
Safety Gaps Remain Despite Efforts to

Address Them

Page 21 GAO- 02- 1017 Increased Risk of Medication Errors

California, a printer for DOD*s CHCS had been installed in the VA pharmacy
so that medication orders from DOD providers could be printed out in the
VA pharmacy. VA pharmacy personnel then re- enter orders into

CPRS to dispense the medications. While these efforts remove the potential
for misreading handwritten prescriptions, they fall short of the full
benefits of electronic ordering and filling because re- entering
information into CPRS introduces the potential for transcription errors.
In August 2002, information technology personnel in Hawaii implemented an
electronic link that allows outpatient medication orders entered into CHCS
for VA patients to be transmitted directly into CPRS, eliminating the need
for manual re- entry in the VA pharmacy. Officials involved in the Hawaii
project told us that this link is working well and that this technology
was developed with the intent of transferring it to other sites. They also
told us that the project was developed with the ultimate intent of two-
way* or bi- directional* communications, so that with some additional
modification a link could be established allowing VA physicians to send
CPRS medication orders to CHCS at Tripler for processing and filling.

Three joint venture sites have taken steps to compensate for problems
associated with drug interaction checks for shared patients. For example,
VA physicians in Hawaii told us that when they provide prescriptions for
dual eligibles to be filled at DOD*s pharmacy, they also enter them into
VA*s CPRS and mark them *hold* so that they will not be dispensed by the
VA pharmacy. Thus, checks for interactions with other drugs prescribed by
VA can be performed by CPRS, and the patients* medication information will
be updated to reflect the medication orders. In Texas, VA adds information
to CPRS about care and medications provided to

referred patients by DOD physicians. This information is recorded in a
special section of CPRS. When VA physicians subsequently access patients*
records, CPRS alerts them that new information has been added to this
section of the record, but the information is not included in automatic
drug checks. The VA clinic in Anchorage, Alaska, uses a different approach
to address the problem of incomplete medication records. Officials there
told us they have developed software to supplement information in the CPRS
record by capturing and displaying information about drugs obtained from
DOD and other non- VA sources, including herbal supplements and over- the-
counter drugs. Thus, providers and pharmacists have additional information
that might help them prevent adverse drug interactions. However,
information collected in this way may not be accurate or complete because
it depends on patient recall and is entered manually. In addition, this
information is not accessed by CPRS*s

Page 22 GAO- 02- 1017 Increased Risk of Medication Errors

automatic drug checks because it is a supplement to, not a part of, the
CPRS record.

Finally, five joint ventures have instituted practices to address safety
problems related to separate formularies. For example, the Mike
O*Callaghan Federal Hospital at Nellis Air Force Base in Nevada has a
combined P& T committee that includes both VA and DOD representatives who
select the medications that will be included on the hospital*s inpatient
formulary. In addition, the committee approved nearly 50 VA formulary
medications to be stocked in the hospital pharmacy for use by VA
inpatients at this facility. All measures taken to improve medication
safety, such as entering reminders or alerts into CHCS to safeguard
against medication mistakes, also apply to VA drugs stocked in the
pharmacy. Other sites have undertaken less comprehensive measures to
address problems arising from separate formularies. For instance,
pharmacies at two sites stock drugs commonly prescribed for the other
agency*s patients, but neither host agency*s P& T committee has
representatives from both agencies. At two other sites, representatives
from both agencies are on the host agency*s P& T committee. While these
efforts are helpful in overcoming difficulties associated with separate
formularies, none is a complete solution.

As VA and DOD strive to improve efficiency and access to care through
greater collaboration and sharing of resources, it is likely that the
number of patients who receive care from both systems will increase.
Consequently, the safety of shared patients merits continuing concern.
While our findings are based on the joint venture sites, they may have
relevance wherever patient care is shared between VA and DOD.

Some joint ventures have taken steps to address medication safety problems
for shared patients, but these steps are partial solutions and gaps
remain. For example, facilities have provided only limited access to the
other agency*s patient medical information system and have not always
provided training in its use. Therefore, providers do not have adequate
access to patient medical information for shared patients, and lacking the
comprehensive capability afforded by a system like PDTS, they can perform
only incomplete checks for drug interactions and allergies. In addition,
when shared patients return to their home agency to have prescriptions
filled, providers give them handwritten or computer- printed
prescriptions, rather than electronically ordering medications, creating
risk for legibility or transcription errors. Furthermore, separate P& T
committees may be unable to effectively overcome problems that arise
Conclusions

Page 23 GAO- 02- 1017 Increased Risk of Medication Errors

from separate formularies. The measures already taken by some joint
ventures show that risks that shared patients face can be addressed. VA
and DOD could develop systemwide rather than local solutions to address
the needs of shared patients nationally as well as at the joint venture
sites. To better protect shared patients at the joint ventures, we
recommend that

the Secretary of Veterans Affairs direct the Under Secretary for Health
and that the Secretary of Defense direct the Assistant Secretary of
Defense for Health Affairs to

 develop the capability for VA and DOD providers to access patient
medical information relevant to medication decision making, regardless of
whether that information resides in VA*s or DOD*s information system and
provide training to physicians and pharmacists who need to use this
access;  develop the capability to perform a comprehensive, automatic
drug

interaction check that uses medication information from all VA and DOD
facilities and mail order operations and DOD*s network pharmacies, and
evaluate the potential for DOD*s PDTS to be used for this purpose; 
require providers to use computerized order entry of medications for

shared patients where it is available and implement system modifications
that will enable providers to electronically order medications to be
dispensed at the other agency*s pharmacies; and  establish a joint VA and
DOD pharmacy and therapeutics committee, or

similar working group, at each joint venture site to determine how best to
safely meet the medication needs of VA and DOD shared patients and to
overcome obstacles associated with separate formularies.

The Department of Veterans Affairs and the Department of Defense provided
written comments on a draft of this report. These comments are discussed
below and reprinted in appendix I and appendix II, respectively. VA
concurred with all our recommendations, while DOD concurred with two of
our recommendations, partially concurred with one, and did not concur with
one.

Both VA and DOD concurred with our recommendation to develop the
capability for VA and DOD providers to access patient medical information
in both CPRS and CHCS. In their comments, both agencies discussed longer-
term solutions, such as the joint VA- DOD Federal Health Recommendations

For Executive Action Agency Comments and Our Evaluation

Page 24 GAO- 02- 1017 Increased Risk of Medication Errors

Information Exchange (FHIE) initiative. 32 While we support long- term
efforts that would lead toward a more seamless sharing of information
between VA and DOD, we believe that a number of joint venture sites have
demonstrated that interim steps, such as giving providers access to and
training on the other agency*s system, are both warranted and feasible.

Both agencies also concurred with our recommendation regarding the
development of comprehensive, automatic drug interaction checks, including
the evaluation of PDTS for this purpose. VA stated that this capability
would be accomplished with the second phase of the VA- DOD joint plan,
called HealthePeople (Federal), which VA expects to be implemented in
fiscal year 2005. Although agreeing to evaluate the cost benefit of
adopting PDTS, VA said that, based on VA and DOD workload data, a
relatively small number of veterans had been treated in both systems in
the period from October 2001 through May 2002 (240,716 unique patients, or
29.6 percent of all dual eligibles) and raised the issue of whether the
cost of PDTS was justified for so few cases. We believe this

almost quarter of a million patients represents a significant opportunity
for adverse drug events to occur, especially since, based on the
prescription patterns of a typical VA patient, this group received an
estimated 4 million prescriptions in this 8- month period. 33 Furthermore,
the number of patients potentially at risk is larger than the dual
eligible group. It includes an

unknown number of patients who receive care and medications from both
agencies under VA- DOD resource sharing agreements. While we agree that
cost is an important factor, we believe the large number of prescriptions
for these patients justifies an evaluation of PDTS that considers both
cost and patient safety.

32 The mission of FHIE, formerly known as the Government Computer- Based
Patient Record (GCPR) project, is to enable the electronic exchange of
selected health information between VA and DOD. Begun in 1998, GCPR was
intended to provide for the sharing of clinical patient data among VA,
DOD, and the Indian Health Service (IHS). Initial plans for GCPR called
for deployment in October 2000, but, as we reported in 2001, the project
suffered from expanding time frames and cost estimates and was refocused.
For further details see U. S. General Accounting Office, Computer- Based
Patient Records: Better Planning and Oversight by VA, DOD, and IHS Would
Enhance Health Data Sharing,

GAO- 01- 459 (Washington, D. C.: Apr. 30, 2001). 33 VA filled 100 million
prescriptions and treated 3.8 million unique patients in fiscal year 2001
for an average of 26 prescriptions per person for the year.

Page 25 GAO- 02- 1017 Increased Risk of Medication Errors

VA concurred and DOD partially concurred with our recommendation on CPOE.
VA said it has already planned for its providers to use computerized order
entry for all orders, including medications, by fiscal year 2004. It also
made reference to the Hawaii pilot project discussed earlier in this
report as a way of extending this capability for shared patients but said
that a more robust bi- directional capability would be included as a
systems requirement in the HealthePeople (Federal) effort. DOD also agreed
to require that providers use CPOE for shared patients where available;
however, it did not agree with system modifications as the approach for

extending this capability. Instead, DOD advocated the joint procurement of
a commercial off- the- shelf pharmacy information system. It said that
this approach would provide greater economic returns and system
interoperability since both agencies are pursuing plans to upgrade or
replace their pharmacy information system modules. We agree with this
approach as a longer- term solution. However, agency officials told us
that neither agency has plans to upgrade or replace its system until
fiscal year 2005 at the earliest, leaving shared patients at continued
risk for medication errors until the new system is operational. System
modifications already accomplished in Hawaii indicate that interim steps
toward reducing these risks are possible.

VA concurred with our recommendation on establishing a joint P& T
committee or similar working group at each joint venture site and said it
would pursue this recommendation via the VA/ DOD Executive Committee, a
working group for VA/ DOD collaboration issues. DOD did not concur with
establishing a joint P& T committee at each site; however, we recommended
the establishment of a joint VA- DOD group, either a P& T committee or a
similar working group, that would determine how best to safely meet the
medication needs of shared patients at each site. DOD expressed support
for the already- established working groups, but, as we have noted, only
three joint venture sites have such collaborative groups. We are sending
copies of this report to the Secretary of Veterans Affairs,

the Secretary of Defense, and other interested parties. Copies will also
be made available to others on request. In addition, the report is
available at no charge on the GAO Web site at http:// www. gao. gov. If
you or your staff

Page 26 GAO- 02- 1017 Increased Risk of Medication Errors

have any questions about this report, please contact me at (202) 512-
7101. Other contacts and major contributors are listed in appendix III.

Sincerely yours, Cynthia A. Bascetta Director, Health Care* Veterans*

Health and Benefits Issues

Appendix I: Comments from the Department of Veterans Affairs

Page 27 GAO- 02- 1017 Increased Risk of Medication Errors

Appendix I: Comments from the Department of Veterans Affairs

Appendix I: Comments from the Department of Veterans Affairs

Page 28 GAO- 02- 1017 Increased Risk of Medication Errors

Appendix I: Comments from the Department of Veterans Affairs

Page 29 GAO- 02- 1017 Increased Risk of Medication Errors

Appendix I: Comments from the Department of Veterans Affairs

Page 30 GAO- 02- 1017 Increased Risk of Medication Errors

Appendix II: Comments from the Department of Defense

Page 31 GAO- 02- 1017 Increased Risk of Medication Errors

Appendix II: Comments from the Department of Defense

Appendix II: Comments from the Department of Defense

Page 32 GAO- 02- 1017 Increased Risk of Medication Errors

Appendix III: GAO Contacts and Staff Acknowledgments

Page 33 GAO- 02- 1017 Increased Risk of Medication Errors

Deborah L. Edwards, (202) 512- 7101 Keith E. Steck, (202) 512- 9166 In
addition to those named above, the following staff members made key
contributions to this report: Irene J. Barnett, Linda Diggs, Mary W.
Reich, Karen Sloan, and Thomas Walke. Appendix III: GAO Contacts and Staff

Acknowledgments GAO Contacts Acknowledgments

(290163)

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