An Arkansas pathologist made over 3,000 diagnostic errors during his 12-year tenure at a U.S. Department of Veterans Affairs (VA) hospital, according to a VA inquiry released on June 2. The report said there were "oversight failures" that led to failure to recognize that Dr. Robert Morris Levy was impaired due to alcohol use.
Levy was chief of pathology and laboratory medicine at Veterans Health Care System of the Ozarks in Fayetteville until he was terminated in 2018, two years after he had completed a substance abuse program that was ordered after he was accused of working under the influence of alcohol.
The VA's Office of the Inspector General (OIG) began an investigation in 2018 after learning that Levy was charged with misdiagnosing pathological specimens and altering quality management documents at the facility to conceal errors. Levy subsequently was charged with incorrect and misleading diagnoses that led to the deaths of three veterans; in 2021 he pleaded guilty to involuntary manslaughter and mail fraud charges in connection with the case.
In its report, the OIG said it largely substantiated the accusations. Inspectors reviewed 34,000 pathology cases over Levy's 12-year career at the VA, with clinical reviewers finding over 3,000 diagnostic errors. Of these, 34 errors were classified as having the potential for serious injury.
The report noted that Levy was the service chief of a pathology department with only one other pathologist on staff. He was also chairperson of three pathology quality management committees, giving himself the opportunity to subvert the quality control process.
What's more, leaders at the VA facility failed to recognize that Levy was manipulating quality data and to address signs that he was operating in an impaired state.
The report acknowledged that the VA facility began its own inspection in October 2017, after Levy appeared to be impaired during work hours and was removed from the clinical setting. Levy was suspended, and as the facility was preparing paperwork to revoke his privileges, he was arrested during duty hours on suspicion of driving while intoxicated. His employment was terminated in July 2018.
As the VA facility began investigating Levy's work, it discovered more errors than it had expected, and called in a team from the Veterans Health Administration for assistance. The team began a review of 100% of Levy's cases since his employment began in 2005, consisting of almost 34,000 cases.
Of the 3,000 errors, 589 were determined to be "major diagnostic discrepancies" interpreted by Levy. In one case, a patient underwent a prostate biopsy in 2012 that Levy reported to be benign; reviewers found cancer in two of six biopsy specimens. The patient was notified of a cancer diagnosis in 2018 and died in late 2020 after receiving palliative care.
In another case, Levy in 2014 diagnosed a patient as having small cell cancer. But the VA review determined that the patient actually had squamous cell cancer; the patient died about a year after Levy's initial diagnosis.
The report noted that Levy was removed from clinical practice at the VA facility in 2016 after registering a high blood alcohol content during working hours. He was allowed to return to work several months later after attending a treatment program, and he agreed to regular testing for drug and alcohol use.
All of Levy's urine and blood tests were negative for drugs and alcohol, but he later told VA investigators that he had purchased a substance online that was similar to alcohol but more potent, and that was not detected by routine test methods, the report noted. Levy finally was suspended after the October 2017 incident, when he appeared to be drowsy, glassy-eyed, and slurring his words.
Levy in January 2021 was sentenced to serve 20 years in prison and pay $489,000 in restitution to the VA, but he appealed the sentence one week later, the report noted.
The OIG report goes on to describe the failures in quality control at the VA facility that enabled Levy's errors to go undetected for so long. Investigators found that senior leaders at the site "missed opportunities" to address Levy's impairment, and staff did not report him either due to concerns about reprisal or because of a perception that others had reported him.
"Any one of these breakdowns could cause harmful results," the report noted. "Occurring together and over an extended period of time, the consequences were devastating, tragic, and deadly."