Multiple Failures in Test Results Follow-up for a Patient Diagnosed with Prostate Cancer at the Hampton VA Medical Center in Virginia

The Office of Inspector General (OIG) conducted a healthcare inspection to assess concerns regarding facility providers’ failures to communicate, act on, and document a patient’s abnormal test results. The OIG also evaluated the facility’s quality management processes in response to identified deficiencies in the patient’s care. The OIG identified multiple providers’ failures to communicate, act on, and document abnormal test results from July 2019 until April 2021, when the patient was diagnosed with metastatic prostate cancer. In July 2019, a vascular surgeon failed to communicate and act on an abnormal CT scan, which noted a potentially malignant lesion in the prostate gland. In September 2020, a nurse practitioner failed to adequately address the patient’s urologic complaints during telephone triage call. In fall 2020, a primary care provider failed to communicate test results to the patient and to act on an abnormal PSA test result by not performing follow-up tests or consulting a urologist. In March 2021, the primary care provider failed to correctly enter bone scan orders in the electronic health record. A technologist attempted to correct this error; however, a facility registered nurse with no knowledge of the patient was entered as the ordering provider. Consequently, the results, which showed possible metastatic bone disease, were not sent to a provider. In April 2021, the patient’s new primary care provider became aware of the bone scan findings and communicated the results to the patient. The OIG concluded that the failures contributed to a delay in the diagnosis of prostate cancer. Additionally, the OIG found that facility leaders did not initiate peer reviews within three days and facility staff did not submit patient safety reports as required. The OIG made seven recommendations to the facility director related to communication of abnormal test results, entering imaging orders, urology consults, and quality reviews.