Healthcare Inspection Delay in Cancer Diagnosis and Treatment Clement J. Zablocki VA Medical Center Milwaukee, Wisconsin

The purpose of this review was to determine the validity of allegations regarding a delay in cancer diagnosis, treatment, and determine whether staff disclosed the adverse event to the patient. We substantiated that there was a delay in cancer diagnosis and treatment, a radiologist failed to identity a lung nodule, the primary physician failed to follow up on the lung nodule, and a second radiologist failed to notify the primary physician. We also substantiated that staff initially failed to disclose the adverse event to the patient. We recommended that managers conduct a formal peer review and root cause analysis on all activities involving care of the identified patient, staff adhere to VHA and local incident reporting and adverse event disclosure policies and procedures, and managers consult Regional Counsel regarding disclosure to the family and explanation of rights.