VA Missed Two Warnings Before Patient Death

By Walter F. Roche Jr.

A primary care physician and a clinical pharmacy specialist at the Nashville Veterans Administration failed to take proper action on a patient who was later diagnosed with pancreatic cancer and died.
That was the conclusion of the VA's Inspector General in a 15-page report issued this week. According to the report the omissions resulted in a three month delay in the patient's diagnosis and treatment.
"The OIG was unable to determine if immediate action by the Clinical Pharmacy Specialist would have led to this patient receiving a prompt diagnosis and treatment," the report states.
According to the report the specialist failed to inform the patient, who was in his 60s, of an abnormal liver test result. He also failed to initiate a change in the patient's care plan, based on those abnormal results.
In addition a primary care physician who examined the veteran in 2018 failed "to acknowledge or assess" the patient's unintentional weight loss of 48 pounds in one year.
"Unintentional weight loss may be symptomatic of a disease process and must be further evaluated," the IG stated.
The physician, who is no longer with the VA could not be reached by IG investigators who visited the Nashville facility in 2019.
According to the report the pharmacy specialist told investigators that he did not recall the specific case, but said it was normal practice to take no action if the test results were considered insignificant.
"The OIG does not believe the laboratory results were clinically insignificant," the report states, adding that the minimum expected plan of care for the patient should have included repeat liver function testing within four to six weeks and communication of test results to the patient."
In addition, the IG stated, the patient should have been counseled on warning signs of a worsening condition.
According to the report the patient returned to the VA three months after the annual physical complaining of abdominal pain. He was subsequently diagnosed with pancreatic cancer and died in the spring of 2019.
The report also cites deficiencies in the VA's electronic health records which do not have a "fail safe" feature that could have triggered a reassessment of the patient's condition at an earlier date.
The report also faults the local facility's management for two inadequate responses to the initial inquiry.
Contact: wfrochejr999@gmail.com