A letter from U.S. Senator Tammy Duckworth (D-IL) sparked an investigation into four radiology errors by a single radiologist -- who was later dismissed -- at a U.S. Department of Veterans Affairs (VA) hospital in Illinois.
The VA's Office of the Inspector General (OIG) conducted the investigation into the VA Illiana Health Care System in Danville at the request of Duckworth's office, which was acting at the request of a constituent, according to a report filed by the OIG on May 5.
The complaint charged that leaders of the radiology service at the Illiana hospital had failed to adequately investigate four cases of errors in image interpretation by a radiologist at the hospital. An initial investigation of almost 200 cases interpreted by the radiologist found an error rate of 16.7%; a review of a larger sample of almost 3,500 cases found an error rate of 13%. These figures were compared with the nationally accepted standard error rate of about 5%.
OIG investigators found that at least one of the errors contributed to a five-month delay in a cancer diagnosis, with the patient subsequently dying while undergoing treatment. Due to the radiologist's high error rate, the investigators determined that the facility should perform large-scale disclosure of the errors and report them to outside agencies.
The investigators further found that the Illiana hospital's radiology service did not have an early detection and identification process for radiology errors. However, once errors were identified, facility leaders took appropriate action.
The OIG made a number of recommendations regarding guidelines to better inform professional practice evaluations of radiologists, including appropriate patient follow-up and disclosure to families, as well as specific recommendations for oversight of the Illiana VA facility.
The radiologist who was the subject of the inquiry was subsequently terminated in January 2019. The chief of radiology at the Illiana VA left in December 2017.
