Pathology Oversight Failures at the Veterans Health Care System of the Ozarks in Fayetteville, Arkansas

The VA Office of Inspector General (OIG) initiated a healthcare inspection in spring 2018 after receiving allegations that former Pathology and Laboratory Medicine Service Chief Dr. Robert Levy misdiagnosed pathological specimens and altered quality management documents to conceal errors at the Veterans Health Care System of the Ozarks in Fayetteville, Arkansas. The inspection was completed after the OIG Office of Investigations conducted a criminal investigation. In January 2021, Dr. Levy was sentenced to 20 years in prison for manslaughter and mail fraud.The OIG substantiated the allegations. After a comprehensive, retrospective review of cases Dr. Levy interpreted over his 12-year tenure (almost 34,000 cases), clinical reviewers identified more than 3,000 diagnostic errors. The need for disclosures of errors causing serious injury was identified for 34 patients.As service chief of a specialty care department with only one other pathologist and chairperson of three pathology quality management committees, Dr. Levy had the opportunity to subvert the quality process. Facility leaders failed to recognize his manipulation of quality data. Dr. Levy admitted to long-term alcohol use. The OIG found that facility leaders missed opportunities to address signs of an impairment. The failure of facility leaders to promote a culture of accountability likely led to minimal reporting of Dr. Levy’s signs of impaired behaviors.The OIG made 10 recommendations to the Under Secretary for Health related to competency and pathology quality management processes, pathology reports, and the consulting process with external pathologists. The OIG also recommended the Office of General Counsel and the Office of Human Resources and Administration/Operations, Security & Preparedness be consulted about administrative actions for VHA leaders, as appropriate. Two recommendations focused on alcohol testing and management of impaired healthcare workers.Two recommendations to the Facility Director addressed peer references during reappraisal and evaluation of the facility’s psychological safety climate.