|Title:||Facility Oversight and Leaders’ Responses Related to the Deficient Practice of a Pathologist at the Hunter Holmes McGuire VA Medical Center in Richmond, Virginia|
|VA Office:||Veterans Health Administration (VHA)
|Report Author:||Office of Healthcare Inspections
|Report Type:||Healthcare Inspection
The VA Office of Inspector General (OIG) conducted an inspection to evaluate facility oversight and leaders’ response to a pathologist’s practice at the facility. The OIG found the Pathology and Laboratory Medicine Chief (Chief) followed VHA policy and performed a quality review of surgical pathology cases and reported the pathologist’s initial misdiagnosis. Facility leaders ensured the required comprehensive clinical care reviews were conducted, resulting in the discovery of 10 additional misdiagnoses. The pathologist also misdiagnosed a skin biopsy.