Concerns Related to the Management of a Patient’s Medication at Three VA Medical Centers and Inaccurate Response to a Congressional Inquiry at the VA Illiana Health Care System, Danville, Illinois

This healthcare inspection assessed allegations that over a multi-year period, providers at three facilities ordered or continued to order a high dose of an antidepressant medication amitriptyline for a patient who was not told about the risks of the high dose, and was experiencing some side effects associated with the medication. Additionally, when asked about attempts to reduce the dose of the patient’s medication, the VA Illiana Health Care System (system) in Danville, Illinois, provided Senator Joe Donnelly inaccurate information. The Office of Inspector General (OIG) substantiated VA providers did not explain to the patient that the amitriptyline dosing was higher than the drug labeling for outpatients or the risks of the high dosage during the period of care from 2012 through mid-2018. In 2012, a provider at the Orlando VA Medical Center (VAMC) in Florida ordered an electrocardiogram but did not inform the patient about an abnormality or discuss the potential that the high dose of amitriptyline contributed to the abnormality. At another VAMC in Indianapolis, Indiana, the ordering provider did not notify the patient that 2016 test results indicated a subtherapeutic level of amitriptyline. At the system, there was no follow-up to the patient’s expressed cardiac concerns due to a failed collaboration between the system’s treating psychiatrist and a primary care provider. Due to other potential causes, the OIG was unable to substantiate the patient experienced tachycardia or short-term memory loss because of taking amitriptyline. The system’s response to Senator Donnelly was not timely and included inaccurate information. The OIG made eight recommendations related to evaluations of the patient’s cardiac care, patient notification of electrocardiograms and blood tests, the strengthening of system processes for effective clinical consultation between providers and congressional inquiry responses, and an evaluation of system staff actions in preparation of the letter to Senator Donnelly.