An investigation into complaints about medical imaging services at a U.S. Department of Veterans Affairs (VA) health system serving northern Florida and southern Georgia has been resolved without any major irregularities discovered, and the VA has closed the case without taking any action.
The VA's Office of Inspector General (OIG) launched an investigation into the North Florida/South Georgia Veterans Health System after receiving two separate complaints that patients received inappropriate treatment that resulted in death or harm, and that the system's diagnostic imaging service was not properly supervised. The health system operates Malcom Randall VA Medical Center in Gainesville, FL, and Lake City VA Medical Center in Lake City, FL.
There were several allegations against the system, including the following:
- Patients with documented allergies to contrast had received CT exams with contrast, resulting in patient deaths.
- Radiologists failed to review orders for CT exams.
- The system lacked after-hours support for CT technologists.
- The CT scanner at the Lake City campus was beyond its useful life and broke down weekly.
- A CT staff member from the Lake City campus was absent for a protracted period of time without being replaced.
- Ureteral stent placements were performed in the Gainesville cytoscopy clinic without general anesthesia.
To investigate the charges, OIG conducted site visits from July 15-19, 2013, interviewing staff in the diagnostic imaging and urology departments. Investigators also reviewed patient records, staff meeting minutes, system quality management documents such as CT wait times, and other sources of information.
Investigators identified 32 patients who underwent procedures consistent with the stent placement allegations, along with 16 patients who died after receiving CT contrast, according to OIG's report.
For the CT contrast allegation, the investigators found that some patients with documented allergies received CT contrast, but they did not conclude that any patient deaths occurred as a result of contrast administration. Investigators found that staff screened for contrast allergies and used pretreatment procedures when contrast use was unavoidable in patients with documented allergies.
The investigators were unable to substantiate allegations that radiologists failed to review CT orders, or that the health system lacked support for CT technologists after hours. The CT scanner was 8 years old, within the VA's predicted life expectancy of 10 years, and it had uptime rates of 98% to 99% around the time of the inspection. The scanner in question has since been replaced, the report noted.
With respect to the absent CT staff member, investigators found that a staff member had been absent for a protracted period of time without being replaced or staffing levels being maintained through alternative measures. However, investigators did not find that the absence resulted in a backlog of patients. The staff member had returned and was working during OIG's site visit.
Investigators found that ureteral stent placements had been performed at the Gainesville cytoscopy clinic without general anesthesia; however, other measures were taken to provide pain control. OIG was also unable to substantiate allegations that procedures were performed in the clinic setting so that urology resident physicians could perform a required number of stent placements for professional education.
OIG investigators concluded the report without making any recommendations.
