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. § 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. 

Floridaa

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, § 101, 110 Stat. 3177, 3179 (1996). VA's implementing regulations 

are found at 38 C.F.R. §§ 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, §§ 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). 

10U.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 

 11Lucian L. Leape and others. “Systems Analysis of Adverse Drug Events,” The Journal of 

the American Medical Association, vol. 274, no. 1 (1995). 

12U.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, 

 13DOD 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. 

14JCAHO Sentinel Event Alert, Issue 19, May 2001. 

15By 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. 

16Institute of Medicine, Description and Analysis of the VA National Formulary 

(Washington, D.C.: National Academy Press, 2000). 

17In 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 § 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. 

 18CPOE allows direct entry of medication orders by a prescriber into a system that 

electronically transmits these orders to the pharmacy for filling. 

19David 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). 

20DOD is evaluating a new pharmacy package that would include inpatient ordering 

capability; however, officials were unable to provide us with an expected implementation 

date. 

21Chemotherapy 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. 

 22VA 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. 

23Although 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. 

24Such 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. 

25Mark 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

 26Neither agency has an inpatient facility at Key West. 

27Homeless 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. 

 28While 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 

 29Dual eligibles face a similar situation when they use VA providers but have their 

prescriptions filled by DOD or vice-versa. 

30In 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 

 31President’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. 

 32The 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). 

33VA 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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