OIG Seal
Department of Veterans Affairs, Office of Inspector General
Michael J. Missal, Inspector General

Report Summary

Title: Healthcare Inspection – Quality of Care Issues, Erie VA Medical Center, Erie, PA, and VA Pittsburgh Healthcare System, Pittsburgh, PA
Report Number: 13-01855-336 Download
Issue Date: 9/25/2013
City/State: Erie, PA
Pittsburgh, PA
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: Healthcare Inspections
Release Type: Unrestricted

The OIG conducted an inspection to evaluate the care and services a patient received at the Erie VA Medical Center, Erie, PA; the Warren Community Based Outpatient Clinic, Warren, PA; and the VA Pittsburgh Healthcare System, University Drive Campus, Pittsburgh, PA. OIG substantiated the allegations that VA providers missed the patient’s cancer diagnosis, did not manage his pain appropriately, and that there were scheduling delays in the patient’s referrals and follow-up care. We could not confirm the allegation that an outpatient specialty care provider was rude to the patient and family during the patient’s care visit. We found factors that contributed to the missed diagnosis as well as opportunities for improvement in system processes that affected this patient’s care. The oversight of the patient’s care continuum was lacking, and there was inadequate communication between primary and specialty care providers and VA and community health care facilities.

We recommended that the Network Director initiate a root cause analysis to evaluate system issues outlined in this report and evaluate the care of the patient discussed in this report with Regional Counsel for possible disclosure to the surviving family member(s) of the patient. The Network Director concurred with our recommendations and provided an acceptable action plan.