Report Summary

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
Report Number: 19-07600-215 Download
Issue Date: 7/29/2020
City/State: Richmond, VA
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: Healthcare Inspection
Release Type: Unrestricted

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.

The Chief followed Veterans Health Administration (VHA) policy for secondary reviews of the misdiagnoses, completed supplemental reports, and documented provider notification. The OIG found no documentation that providers informed three patients of their misdiagnoses. The OIG learned one patient experienced an adverse clinical outcome and did not have any documented disclosures. Also, facility staff and leaders did not report any of the misdiagnoses as adverse events.

Facility leaders summarily suspended the pathologist; however, the OIG found no documentation renewing the suspension. The Facility Director then terminated the pathologist. The pathologist appealed the termination through the VHA Disciplinary Appeals Board, which recommended a reinstatement. The pathologist was reinstated, and clinical privileges were restored. Facility leaders did not comply with VHA’s mandated privileging processes and were unaware of who was responsible for state licensing board reporting.

Quarterly retrospective reviews of all pathology reports exceeded the 10 percent standard; however, the Chief and staff pathologists did not consistently review 10 percent of each pathologist’s cases. The Chief and staff pathologists reviewed 9.4 percent of the pathologist’s cases, below the 10 percent requirement.

The OIG made 10 recommendations related to test results, disclosure and reporting of adverse events, issue briefs, the summary suspension process, the credentialing and privileging process, state licensing board reporting, and quality reviews of the pathologists’ work.