Alleged Adverse Outcomes and Access Issues in Diagnostic Imaging Services, North Florida/South Georgia Veterans Health System, Gainesville, Florida

OIG conducted an inspection in response to complaints about diagnostic imaging services at the North Florida/South Georgia Veterans Health System, Gainesville, and Lake City, FL. We substantiated that some patients with documented contrast media (contrast) allergies received contrast for Computed Tomography (CT) exams; however, there were processes in place to address potential adverse effects of contrast administration. We did not substantiate that patient deaths occurred as a result of contrast administration. We substantiated that ureteral stent placements were performed in a cystoscopy clinic without general anesthesia; however, we found that other appropriate measures were taken to provide pain control. Further, we did not substantiate that the clinic setting was chosen so that urology resident physicians could perform a required number of stent placements for professional education. We substantiated that a staff member in the CT department was absent for a protracted period but did not substantiate that the reduced staffing resulted in a backlog of patients. We did not substantiate that a pre-procedure marking was incorrect or that a patient’s bowel was perforated. We did not substantiate that after-hours radiologist support was lacking for CT technologists at the Lake City campus. We did not substantiate that the CT scanner at the Lake City Campus was beyond its useful life and broke down weekly. The scanner had been serviced by the manufacturer with an up-time rate greater than 98 percent. A new scanner has recently been installed in accordance with a routine replacement schedule. We made no recommendations.