Patient and Radiation Safety Concerns at the John D. Dingell VA Medical Center, Detroit, Michigan

The VA Office of Inspector General (OIG) conducted a healthcare inspection regarding allegations of patient and radiation safety concerns at the John D. Dingell VA Medical Center, Detroit, Michigan. To reduce the risk of unnecessary radiation exposure, the Veterans Health Administration (VHA) requires that radiology staff ensure equipment is operating properly, follow appropriate procedures, use shielding and engineered safety features, and ensure radiation doses are as low as reasonably achievable. The OIG substantiated annual radiologic equipment inspections were not performed for most of fiscal years 2015 through 2017, although inspections were current as of April 5, 2018. The OIG substantiated that a radiologist performed fluoroscopy procedures without having current training or privileging and the radiology department did not conform to VHA radiation safety standards. The OIG substantiated that the Chief of Radiology changed the Radiology privileging form; however, the OIG did not substantiate that the form was changed to request and grant authorized user status. Although the OIG substantiated that facility staff were not permitted to perform nuclear medicine studies because the Master Materials License permit was revoked in 2009, it was reinstated in 2010. During the inspection, facility leaders identified portions of the radiation safety program that were not completed in a consistent and timely manner, including deficient equipment testing, lack of lead aprons and shields annual inspections, and dosimeter badges processing. The OIG also identified issues with the nuclear medicine waiting room dosimeter, radiology technicians’ training records, and a tracking matrix. Although the OIG found deficiencies in the Facility’s radiation safety program and made recommendations, the OIG did not identify deficiencies that put patients and staff at immediate risk or warranted stopping patient care. The OIG made six recommendations related to equipment testing, fluoroscopy training, clinical privileges, radiation safety, and tracking and monitoring corrective actions to completion.