Facility Leaders’ Response to Level 2 and Level 3 Pathology Reading Errors at the Veterans Health Care System of the Ozarks in Fayetteville, Arkansas

In follow-up to the VA Office of Inspector General (OIG) report, Pathology Oversight Failures at the Veterans Health Care System of the Ozarks in Fayetteville, Arkansas, the OIG conducted a healthcare inspection to evaluate progress in responding to pathology reading errors identified during a look-back review of cases interpreted by Dr. Robert Levy between September 2005 and October 2017. The OIG determined facility processes related to disclosure of the pathology errors and amending patients electronic health records generally met Veterans Health Administration policy requirements, but opportunities for improvement existed. Look-back reviewers categorized cases according to their disagreement with the original diagnosis and potential harm to the patient (level 0–3). Cases categorized as level 2 or level 3 diagnostic errors were referred to a Clinical Review Team to determine the impact on patient care and need for clinical and institutional disclosure. The OIG determined the facility made reasonable efforts to conduct disclosures, completing all but six of the institutional disclosures and 76.5 percent of the clinical disclosures recommended by the Clinical Review Team. The OIG noted an absence of a clearly defined process for clinical providers to alert the Clinical Review Team if later changes in a patient’s health required reconsideration of institutional disclosure. The look-back review coordinator entered amended pathology reports into the electronic health record for patients identified with level 3 diagnostic errors. However, the facility struggled with completing amended reports for patients with level 2 diagnostic errors—fewer than 5 percent of the level 2 amended reports were completed as of March 2021. The OIG made two recommendations to the Under Secretary for Health related to documentation of clinical disclosures and provider communication to the Clinical Review Team. One recommendation was made to the Facility Director related to amendment of the remaining pathology reports.