Pathology Errors a Factor in 3 Deaths at VA Hospital

33,000 cases handled by the Chief of Pathology since 2005 are under review by other pathologists

CEO SUMMARY: Outside pathologists are reviewing the pathology reports of almost 20,000 patients of an Arkansas Veterans Administration hospital following termination of a Chief of Pathology who was believed to have handled cases while impaired. Currently, the review identified 256 cases where the pathology report missed the diagnoses and the potential for severe consequences existed. Serious consequences have been con rmed in 11 patients and three of these patients are now dead.

THERE IS A NEW CASE OF PATHOLOGY ERRORS that caused patient harm, this time at a Veterans Administration Hospital in Arkansas. News reports say that misdiagnosis is believed to be a factor in the deaths of at least three patients.

A review is underway at Veterans Health Care System of the Ozarks in Fayetteville, Ark., after officials determined that an impaired pathologist’s work led to three deaths. The Veterans Health Care System of the Ozarks serves veterans in 23 counties in Northwest Arkansas, Southwest Missouri, and Eastern Oklahoma.

Chief of Pathology Involved

Pathologist Robert Morris Levy, MD, identified himself to FBSM/KXNW News as the pathologist. Prior to his termination last April, he had been Chief of Pathology at the Veterans Health Care System of the Ozarks. FBSM/KXNW reported that Levy “denied he was impaired on duty.”

In the NWA Democrat-Gazette, J.T. Wampler reported that three deaths resulted from incorrect pathology reports and that a review was underway.

In his news story, Wampler quoted Veterans Health Care System Interim Director Kevin Parks, who said, “The review has found 256 cases in which the pathology report missed the diagnosis with possibly severe consequences. These range from extended, avoidable hospitalization to lasting disability or death.”

In most of the 256 cases, VA officials did not know if the misdiagnosis had any serious consequences. However, serious consequences were confirmed in 11 of those cases, and three of those patients died, Wampler reported. Misdiagnosis is believed to be a factor in at least one death, and the other two cases were being reviewed, he added.

VA officials are reviewing every one of more than 33,000 cases the pathologist has been involved with since he was hired in 2005 and those cases are prioritized by risk, Wampler reported.

Another news outlet said that these 33,000 cases involve 19,794 veterans. They or their family members have been notified by mail about this situation and the fact that the cases are being reviewed.

The review of these cases is expected to be completed by year-end, in part because the University of Arkansas for Medical Sciences has sent nine pathologists to work at the Fayetteville veterans system site fulltime, Wampler wrote. “The system will bring in more pathologists from outside the state, but that will have to wait until the beginning of the new federal fiscal year on Oct. 1,” he added.

A final report will be made public in January, said Wampler. Meanwhile, VA officials who are reviewing the 33,806 case reports have so far gone through fewer than half (14,980) of them, he reported. “Of those reviewed, 9,979 have no errors, 863 appeared to have errors with no lasting consequences to the patients involved and those cases will get a further review, and 3,882 reviews are complete but a final report is not finished,” he wrote. The VA will send letters to patients and families when final results are available.

Was Pathologist ‘Impaired?’

In June, VA officials announced that the review began after administrators discovered that pathologist Levy at the Fayetteville Veterans Administration Hospital tested samples while impaired. The pathologist confirmed that he had worked while impaired with alcohol in 2016, but said he did not work while impaired after that, Wampler wrote. The Veterans Affairs Office of Inspector General is investigating the retention of the pathologist after his first reported impairment, officials said.

Levy was suspended in March 2016 for being impaired, but returned to work in October 2016 after counseling. In October 2017, the pathologist was no longer involved in clinical work after the hospital discovered a second instance of working while impaired, Wampler reported. After a personnel department review, the pathologist was fired in April of this year, he added.

The Minneapolis Star-Tribune reported that, “Levy was licensed to work in California, Florida, and Mississippi (VA doctors do not need to be licensed in the state in which they practice). Online searches reveal active licenses in California and Florida, although Levy has said he does not intend to return to pathology.

U.S. Attorney Is Investigating

During a news conference this summer organized by the Arkansas VA health system, Parks said the nature of the now-terminated pathologist’s impairment would not be publicly disclosed because it is a personnel matter.

The Arkansas Democrat-Gazette reported that U.S. Attorney Duane Kees of the Western District of Arkansas was present at the press conference and did confirm his office was investigating these developments. Kees did not speculate as to what charges, if any, might be under consideration.

These developments happened within months of the news that pathology errors caused patient harm at Wake Forest Baptist University Medical Center in Wake Forest, N.C. In that case, an inspection by officials from the Centers for Medicare and Medicaid Services (CMS) resulted in a decision to pull the hospital’s accreditation. The hospital’s plan of corrective action was accepted by CMS and the hospital’s Medicare billing privileges were restored. (See TDR, April 16, 2018.)

Double Warning to Pathology

These examples of serious pathology errors associated with patient harm should be a double warning to the pathology profession. The patients and the American public are raising their expectations about the quality of healthcare they receive. They also have the expectation that the pathology profession is using quality-management methods to continually reduce the number of errors in how pathology specimens are handled and diagnosed.

 

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