The VA Office of Inspector General (OIG) conducted a healthcare inspection at the request of Senator Tammy Duckworth on behalf of a constituent to assess concerns regarding the appropriateness of facility leaders’ response to a radiologist’s alleged four radiologic errors. The OIG determined that one of the four patients met criteria for institutional disclosure. Alerted to the radiologist’s potential errors, facility leaders conducted an expanded review, with Veterans Integrated Service Network and National Teleradiology Program assistance and found a high error rate in the radiologist’s exams. A second, further-expanded review ensued. The OIG concluded that Radiology Service lacked an effective early detection and identification process for radiologic errors. Once radiologic errors were identified, Veterans Integrated Service Network and facility leaders took appropriate actions. The Radiology Service Chief inadequately assessed the radiologist’s performance due to a small exam sample size and lack of consideration to the modalities and complexities of exams. VA’s National Guidelines for Radiology Professional Competency provide facility leaders with direction to assess radiologists’ clinical competence. Because radiologic exams vary in complexity and risk to patients, a risk stratification methodology would further and better inform professional practice evaluations. The OIG made six recommendations: one to the Under Secretary for Health regarding guidelines to better inform radiologists’ professional practice evaluations; one to the Veterans Integrated Service Network Director regarding continued oversight of the facility’s response to National Teleradiology Program findings; and four to the Facility Director regarding disclosures to patients or families as warranted, Radiology Service improvements in quality assurance and performance plans, consideration for radiologist competency reviews based on VA’s National Guidelines for Radiology Professional Competency, and evaluation of the National Teleradiology Program final findings to determine what additional steps are required.
Danville, IL
United States
