Deficiencies in Disclosures and Quality Processes for Perforations Resulting from Urological Surgeries at West Palm Beach VA Medical Center in Florida

The VA Office of Inspector General (OIG) conducted a healthcare inspection in response to an allegation that a urologist perforated two patients’ organs during procedures. Patients’ organs were perforated by the urologist. The OIG found the facility conducted management reviews and facility leaders took reasonable actions based on the results. The inspection identified deficiencies in disclosures, quality reviews, timeliness of management reviews, and the process for delineating urologists’ privileges. The urologist reported disclosing a bladder and possible colon perforation to the first patient; however, documentation did not reference the possible colon perforation. Moreover, documentation of a disclosure for a confirmed colon perforation was not found. Regarding the second patient, the urologist completed the clinical disclosure four days after the patient’s surgery, inconsistent with Veterans Health Administration policy. Institutional disclosures were not considered for either patient. The OIG concluded that disclosure failures may result in patients not being fully informed. The first patient’s bladder perforation and possible colon perforation were reported to the Patient Safety Manager; however, facility staff failed to report other adverse events. A planned peer review was not completed, and management reviews were delayed. The two patients’ care was presented at Surgical Service Morbidity and Mortality Conferences, but the Surgical Workgroup did not provide required oversight of the conferences. Oversight deficiencies could lead to delayed or missed opportunities to improve quality care. The form delineating privileges for urologists was not reviewed as required. A privileging form statement suggested that urologists may perform procedures beyond those listed, without the safeguards afforded through the required delineation of privileges process. The OIG made seven recommendations to the Facility Director related to disclosures, patient safety reporting, quality review processes, oversight of Surgical Service Morbidity and Mortality Conferences, and the privileging process.