Report Summary

Title: Manipulation of Radiology Reports and Leadership Failures in the Medical Imaging Service at Clement J. Zablocki VA Medical Center in Milwaukee, Wisconsin
Report Number: 18-06074-123 Download
Report
Issue Date: 4/29/2020
City/State: Milwaukee, WI
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: Healthcare Inspection
Release Type: Unrestricted
Summary:

The VA Office of Inspector General (OIG) conducted a healthcare inspection regarding allegations that a radiologist made gross errors resulting in treatment delays and placed misleading report addenda in records, and that leaders were tolerant of this practice.

During the inspection, the OIG found evidence of manipulation and vulnerability of the electronic health record and mismanagement of the Medical Imaging Service. Facility leaders failed to successfully manage or address the impact of interpersonal conflicts within the Medical Imaging Service that included intimidation of staff radiologists. The OIG was concerned that ongoing interpersonal conflicts, coupled with the lack of defined plans for resolution, had the potential to adversely affect patient care.

The OIG did not substantiate that the radiologist made addenda to cover gross errors resulting in treatment delays that contributed to adverse clinical outcomes for two patients or that the radiologist’s use of addenda was misleading. However, the date and location of addenda in radiology reports may hinder transparent communication of clinical information.

Both Veterans Integrated Service Network and facility leaders failed to conduct a thorough and impartial review related to the OIG request to evaluate the original allegations.

The OIG made eight recommendations including two addressed to the Under Secretary for Health regarding addenda, deletion, and formatting features for radiology reports in the new electronic health record, and an evaluation of the circumstances that led to the radiology manager’s deletion of an imaging report. Two recommendations to the Veterans Integrated Service Network 12 Director related to imaging archiving and communication system practices and oversight of OIG hotline case referrals. Four recommendations for the Facility Director focused on correction of the patient’s imaging study, Medical Imaging Service oversight and management, evaluation of Medical Imaging Service’s workplace culture, and evaluation of the need for workplace intimidation training and the process for reporting concerns.