Report Summary

The VA Office of Inspector General (OIG) conducted an inspection to assess concerns regarding delays in clinical care and deficiencies in care coordination that led to a delay in the diagnosis of lung cancer in a patient who died at the Raymond G. Murphy VA Medical Center (facility). The OIG also evaluated facility leaders’ responses to quality and timeliness of care. During the inspection, the OIG discovered limitations in the facility’s teleradiology processes.

The OIG determined that poor oversight of resident physicians (residents) likely contributed to the patient’s delayed lung cancer diagnosis. A resident ordered an abdomen and pelvis computed tomography (CT) scan. Although a follow-up chest CT scan was recommended within 90 days, it took 175 days to complete. The chest CT scan results included resolution of a spiculated lung nodule and worsening of opacities in the lung representing a cavitary infection or cancer, and a positron emission tomography/CT (PET/CT) scan was recommended. The follow-up PET/CT scan showed a lesion in the right lung, but a biopsy was not done. The patient was examined and diagnosed with cancer at a non-VA hospital.

The OIG concluded that deficiencies in care coordination between Primary Care, Pulmonary, and Emergency Departments’ staff also contributed to delays. In addition, contract teleradiologists did not use available prior images for comparison.

The facility failed to use quality management and patient safety processes to evaluate the care of the patient.

The OIG made six recommendations to the Facility Director related to oversight of residents; care coordination between primary, emergency, and specialty care; review of the patient’s care; leader’s review of facility responses provided to the OIG; consistency in the review of relevant radiological images by facility radiologists and contract teleradiologists; and patient safety reporting.