Healthcare Inspection - Misdiagnosis and Alleged Lapses in Courtesy, Fayetteville VA Medical Center, Fayetteville, NC

We evaluated allegations of misdiagnosis and courtesy lapses in the Emergency Department (ED). We substantiated that the patient did not receive an accurate diagnosis during his ED visit. Further, the ED physician did not complete a comprehensive evaluation and did not review the medical record or ask the patient about his current medications. The Service Chief did not adequately address the ED physician’s history of performance deficiencies related to medication reconciliation, and responsible managers did not follow policy when they renewed the ED physician’s clinical privileges. The medical center conducted quality of care reviews, but those reviews did not address the deficiencies identified in this report. We could not confirm or refute the allegation that the ED physician was rude during the patient’s ED visit. We made three recommendations to improve care and processes.