The U.S. Department of Veterans Affairs (VA) has completed an investigation into whether a shortage of pathologists at a VA hospital in Tennessee resulted in harm to patients.
The VA's Office of Inspector General (OIG) launched the investigation after receiving complaints about possible delays in processing surgical specimens at the pathology and laboratory medicine service at the Memphis VA Medical Center. The complaint charged that the delays had resulted in harm to multiple patients and possibly even led to deaths.
However, the OIG found no adverse clinical outcomes from the delays after reviewing the electronic health records of 136 patients.
In 2018, about 39% of positions were vacant at the Memphis VA's pathology and laboratory medicine service, according to the agency. But facility leaders developed a plan for dealing with the delays that involved removing a chief within the service and contracting for an additional pathologist. The changes improved turnaround times for pathology specimens, the OIG investigation found.
The OIG also identified deficiencies in initial training and annual competency documentation at the Memphis VA Medical Center, and due to "inconsistent" leadership in the service, there was no way to ensure that training was completed on a consistent basis. However, the OIG did not find any evidence of attempts to conceal deficiencies in the service.
The OIG made a total of seven recommendations to the facility's director regarding an ongoing process to track specimens, the use of quality processes to identify areas of future risk, staff competency and training, and other issues.
