Registered nurse P.J. Jennings was there, on Halloween night, when the order was made to change a patient's pain medication.
But when she arrived at the Department of Veterans Affairs Medical Center in Salt Lake City the next morning, the patient was still attached to a pain pump and getting regular doses of a morphine derivative known as hydromorphone.
The error was caught and fixed without harm to the Utah patient -- but it was one of scores of cases in which the faulty display of electronic health records resulted in potentially dangerous medical errors at V.A. medical centers nationwide.
The glitches began after the V.A. distributed an annual software upgrade in August. A review of records by the Associated Press found nearly one-third of the V.A.'s 153 medical centers reported instances where patients were given incorrect doses of drugs, missed needed treatments or were exposed to other errors.
The program was fixed by the end of the year. Officials say they know of no cases where a patient was harmed -- but they acknowledge that they cannot be sure how many instances may have gone undetected or unreported, the AP reported.
Two instances of software glitches affecting patient care were reported in Utah. The first case, involving the hydromorphone pump, occurred the same day that the V.A. issued an internal memo warning that the patients might be "at risk for delay in treatment changes or possible medication errors" due to the software problems, according to internal documents obtained by the AP under the Freedom of Information Act.
At the time, however, Jennings said she couldn't understand how the order to discontinue the hydromorphone pump in favor of oral pain medication had been missed. "I was right there," she told The Salt Lake Tribune.
"I watched the doctor put the order in and when I came back the next morning, it was gone," she said.
By the time the V.A. system fully understood the problems, another error had been reported in Salt Lake City.
In that case, a doctor signed an order terminating the delivery of the blood-thinner Heparin for a patient. The order didn't show up at the top of the chart, as it should have, but embedded itself into an order from days earlier. The error occurred on a Friday and wasn't noticed until the following Monday morning.
Wrongful administration of Heparin, which can be life-threatening in excessive doses, was among the most common problems found in the AP's review of the reports. The AP also found cases in which patients were given infusions of either sodium chloride or dextrose mixtures that were prolonged for up to 15 hours past the doctor's prescribed deadline. In other cases, medical data including vital signs and lab results from one patient popped up under another patient's name on the computer screen.
"This is disturbing on a number of levels because of what could have happened," said Veterans of Foreign Wars National Commander Glen Gardner. He was particularly incensed that the V.A. did not disclose the mistakes to the patients.
V.A. spokeswoman Jill Atwood said that the Salt Lake City medical center has no record confirming that either patient known to have been affected by the error was alerted. "That doesn't mean that they weren't informed, but we have nothing that says they were," she said.
The top Republican on the House Veterans Affairs Committee demanded Wednesday that the V.A. explain its actions, the AP reported.
"I have asked V.A. for a forensic analysis of all pertinent records to determine if any veterans were harmed, and I would like to know who was responsible for the testing and authorized the release of the new application," said Rep. Steve Buyer, R-Ind.
The errors came at a time in which the federal government is promoting the universal use of electronic medical records as a way to reduce errors, the AP noted.
