Federal Reports

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the John D. Dingell VA Medical Center (facility) to evaluate allegations of inaccurate complete blood count (CBC) with differential results and reporting, and a laboratory supervisor not passing a proficiency test. The OIG identified concerns regarding quality assurance processes and laboratory leaders’ response, which were not in compliance with VHA Directive 1106, Pathology and Laboratory Medicine Service and VHA Directive 1050.01(1), VHA Quality and Patient Safety Programs. 

The OIG substantiated eight medical technologists (technologists) missed or under reported blast cells, leading to inaccurate CBC with differential results for a patient. The OIG did not identify adverse clinical outcomes. 

Laboratory leaders did not implement a quality assurance process to ensure the accuracy of CBC with differential results. Further, none of the technologists were informed of the inaccurate readings, precluding mitigation of errors. Pathologists completed the OIG-requested retrospective review of readings, but the OIG remains concerned that misreads may continue without sustained oversight.

Laboratory leaders, including the quality management technologist, and patient safety managers, did not ensure corrective actions were timely implemented or tracked. Factors contributing to delayed completion of corrective actions and unresolved patient safety risks included conflicting interpretations of the quality management technologist’s responsibilities and laboratory leaders not following a reporting policy. 

The OIG substantiated a supervisor did not pass a blood bank proficiency test in summer 2024, leading to the suspension of blood bank crossmatch testing services. However, laboratory leaders constructed a contingency plan and completed requirements to resume services within a week.

The Facility Director concurred with the OIG’s five recommendations related to communicating errors to technologists, patient safety staff’s monitoring of action plans, clarification of the quality management technologist’s role, oversight of accuracy for CBC results, and laboratory leaders not following a reporting policy.

We determined that although RMA performs oversight, it does not have the information needed to evaluate whether AIPs and agents are offering all relevant insurance plans to producers which may leave some producers without adequate protection.