VA and Defense Health Care: Increased Risk of Medication Errors for Shared Patients

A letter report issued by the General Accounting Office with an abstract that begins "Medication errors and adverse drug reactions are a significant concern for the Department of Veterans Affairs (VA) and the Department of Defense (DOD) because their large beneficiary populations receive many prescriptions. Each agency has taken steps to reduce the risk of medication errors, such as making patients' medical records more accessible to providers and performing checks for drug interactions. Although each agency has designed safeguards to protect its own patients, some VA and DOD patients receive medication from both agencies. Shared patients face a higher risk of medication error. 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 tried 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.