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Impaired pathologist prompts review

LITTLE ROCK, Ark. (AP) — Federal officials said Monday a pathologist fired from an Arkansas veterans hospital for being “impaired on duty” misdiagnosed seven cases and that more than 30,000 additional cases are being reviewed.

The Veterans Health Care System of the Ozarks in Fayetteville said one error may have led to a death. Spokeswoman Wanda Shull said the seven errors were found among 911 cases already reviewed by the Department of Veterans Affairs and Office of the Inspector General.

According to Shull, the medical center removed the pathologist from clinical care in March 2016 after a colleague reported the pathologist was impaired. The unidentified pathologist returned to work that October after completing a state licensure board-run support program, but was removed from the clinic again last fall. The pathologist was eventually fired in April.

Shull said the pathologist handled about 33,000 cases for nearly 19,800 veterans since being hired in 2005. Inspector General Michael Missal said the earliest identified misdiagnosed case is from 2013. The medical center largely serves veterans in Arkansas, Missouri and Oklahoma but it has analyzed tissue samples for patients across the country.

Because the investigations are ongoing, Shull could not say what impairment was reported. Shull also didn’t say whether criminal charges were being pursued.

The medical center had already identified some missed diagnoses through a constant random sampling the hospital conducts. However, in October 2017, when the pathologist was reported a second time, the medical center began a deeper review of the cases. The VA will continue reviewing the cases, although at least 50 percent of the pathologists helping with the reviews will be outside of the VA, Shull said.

The OIG began investigating the pathologist in mid-May and Missal briefed the Arkansas congressional delegation Thursday.

Missal said the OIG is “taking a comprehensive look” at the situation to determine exactly what happened, why, who knew, and what controls are in place to keep it from happening again.

The medical center has sent out letters to all the patients who had tests reviewed by the physician notifying them of the situation and the VA has opened a call center for concerned veterans.

“We all expect better and our veterans certainly deserve better,” said Rep. Bruce Westerman, who represents the district where the deceased veteran lived. “If there are some who need another diagnosis or need specific care, the first priority is to make that happen.”

The investigations are expected to take months, Missal said.

The VA has been mired in controversy recently after an OIG investigation found “critical deficiencies” at the Washington, D.C. medical center, including taxpayer waste, unsecured patient data and patient safety issues.

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