Delayed Radiology Test Reporting at the Dwight D. Eisenhower VA Medical Center, Leavenworth, Kansas (VA Eastern Kansas Health Care System)

The VA Office of Inspector General (OIG) conducted a healthcare inspection to review the delay in a patient’s diagnosis and care and determine the extent and contributory causes of delays in communicating abnormal test results at the Dwight D. Eisenhower VA Medical Center, Leavenworth, Kansas. After reviewing the patient’s care and the system’s responses to the initial complaint, the OIG opened a healthcare inspection to further review contributory causes of delays that included providers’ failure to accept or acknowledge view alerts, leaders’ failure to update the system’s communication of test results policy, and a manager’s failure to conduct a peer review as required. Although there were delays in providers reporting radiology test results and diagnoses to patients, the OIG could not determine if the delays were due to missed view alerts. There was evidence of ongoing evaluation and care, and the patients reviewed did not suffer adverse outcomes related to the delays. System providers failed to communicate test results needing follow-up within the required timeframe of seven days. The system policy that required test results to be communicated to patients within 14 days had not been updated at the time the patient was seen. Radiologists did not receive training for new national diagnostic codes or software that generates view alerts. An administrative investigation should have been completed as required by VA. The system failed to identify a patient incident that should have triggered a peer review. An institutional disclosure was not completed for the patient. The OIG made five recommendations related to communicating test results, training radiologists, initiating a peer review, conducting an administrative investigation, and initiating an institutional disclosure.