Healthcare Inspection—Alleged Failure in Patient Notification of Test Results, VA Connecticut Healthcare System, West Haven, Connecticut

The VA Office of Inspector General (OIG) conducted an inspection in response to allegations about a failure in notifying a patient of test results at the VA Connecticut Healthcare System, West Haven Campus. The complainant alleged (a) a urologist failed to advise a patient of prostate-specific antigen (PSA) results, and the lack of notification allowed prostate cancer to spread to his lymph nodes and seminal vessels; (b) a provider failed to inform the patient of his high PSA reading greater than (>) 9.0 collected in mid–2015; and (c) 6 months elapsed before he was informed that his PSA was >11.0, and he had prostate cancer. The OIG did not substantiate the provider failed to notify the patient about an elevated PSA test result. The patient had a PSA done on Day 1. According to the patient in an interview, the provider notified him the PSA test result was elevated during a clinic visit on Day 3. The provider documented that the patient should return to the facility the next week for further testing. The significance of the PSA test was not known on Day 3; additional testing was needed to determine the reason for the elevated level. The OIG did not find evidence of a scheduled return appointment or visit the next week for a repeat PSA. The next scheduled appointment was several months later, on Day 134, for a Mental Health Pharmacy visit. A prostate biopsy on Day 227 was positive for cancer. The patient subsequently underwent surgical and radiation therapy. Although the OIG found the patient was informed of his mid-2015 PSA results, the OIG did not find documentation of patient notification regarding the Day 3 abnormal urinalysis test result. The OIG recommended that the Facility Director ensure providers follow Veterans Health Administration policy related to patient notification of test results.