FAYETTEVILLE, Ark. – A former pathologist and pathology and laboratory director who was frequently drunk while on duty made errors in about 10% of the 34,000 cases he reviewed over 13 years, and the errors went unnoticed because this pathologist s he is basically being watched by looking for errors in his department.
That was one of many findings from a 102-page report, released Wednesday by the Office of the Inspector General of the Veterans Administration, on the Ozark veterans health care system in the case of Dr Robert Levy condemned.
Levy, who headed the pathology and laboratory medicine departments until his impeachment in July 2018, pleaded guilty in federal court in 2020 to manslaughter and mail fraud charges and was convicted in January 2021 to 20 years in prison followed by three years of supervised release. He was also ordered to pay $ 498,000 in restitution to the VA.
Levy’s attorney filed a notice of appeal shortly after his conviction.
The report cited numerous reports of Levy appearing to be drunk at work, particularly from 2014 to 2016, and his attempts to cover up alcohol abuse by taking a chemical that allows a person to get drunk but makes l alcohol undetectable in normal drugs and alcohol. trial.
The report said Levy had a drinking problem dating back 30 years.
Errors and consequences
The Inspector General’s report said the 3,000 errors included 589 “major diagnostic deviations interpreted during his stay in the facility.”
“Two examples of patients who presented with major diagnostic deviations illustrate the fatal consequences of Dr. Levy’s actions,” the report said. âA patient underwent a prostate biopsy in 2012 which Dr. Levy reported as benign. Retrospective examiners in 2018 identified cancer in two of six biopsy samples. At the time the patient was informed of the cancer diagnosis in 2018, treatment was limited to palliative care. The patient died at the end of 2020.
âA second patient was treated for small cell cancer after Dr. Levy was diagnosed in 2014. The patient died about a year later. The retrospective examination determined that the patient had squamous cell cancer of the lung, not small cell cancer. Treatment options for squamous cell cancer included surgery, which was not offered to the patient. “
The Inspector General’s report states that Levy’s “huge number of serious misdiagnosis” was the result of Levy’s failure to correctly interpret the specimens.
But the errors went undetected for years, in part “because of its manipulation of pathology quality management data and gaps in quality management processes.”
The VA declined to answer specific questions about the report and issued a prepared statement in response to requests for comment.
âThe Ozarks Veterans Health Care System (VHSO) and the Department of Veterans Affairs are truly saddened by the pain and families endured by this pathologist,â the statement said. “The department assures Veterans that we are fully committed to improving our processes and systems going forward to prevent a situation like this from happening again.” VA has started the process of addressing many of the OIG’s recommendations and plans to complete the rest by May 2022. “
The report says Fayetteville hospital administrators failed to protect patients when hospital staff reported signs that Levy was under the influence of alcohol in 2014-2016.
The report talks about four cases where staff reported Levy to “smell alcohol” or have red eyes or hand tremors, one in 2014, two in 2015, and one in 2016.
The report also states that Levy disclosed a 1996 conviction related to drunk driving when he was hired in 2005 and admitted to a 30-year drinking problem.
After the 2016 report, Levy was “removed from clinical care,” but was allowed to return to work in October 2016 after completing a treatment program.
“Had the facility’s leaders seized the opportunities that presented themselves as early as March 2014 to vigorously respond to allegations of impairment and adequately review Dr. Levy’s clinical skills, his withdrawal may have occurred sooner,” says The report. “A thorough review of Dr. Levy’s cases and an assessment of his skills prior to his reinstatement in 2016 would likely have revealed similar results on the retrospective review and may have precluded the institution’s decision to return Dr. Levy to clinical practice.” . The Chief of Staff informed the OIG that the lack of evidence of adverse clinical outcomes for patients was factored into the decision that allowed Dr Levy to resume clinical services in October 2016. â
The Inspector General’s report cited a failure to “foster a culture of accountability” in the process that allowed Levy to continue working with patients despite reports of problems.
âWhile the OIG recognizes that providers with disabilities should be offered assistance in appropriate situations, senior leaders have missed opportunities to treat Dr. Levy’s disability,â the report said. âThe OIG discovered a culture in which staff did not report serious concerns about Dr. Levy, in part because of a perception others had reported or feared retaliation. Any of these failures could lead to harmful results. Occurring together and over a long period of time, the consequences have been devastating, tragic and deadly. “
In its written response, the VA said it has changed processes in the veterans’ health care system in the Ozarks and nationwide to ensure that the care provided does not harm patients.
The statement said the administration has “strengthened internal controls by ensuring that no vendor can review their own work and by providing more stringent oversight, policy and processes.”
He listed six specific policy and process changes:
â¢ Execution an IL-wide policy requiring establishments with two or fewer providers in a given specialty to conduct provider reviews at another IL establishment with similarly qualified specialist providers, ensuring independent and objective oversight.
â¢ Assess current guidelines for impaired healthcare workers and explore the possibility of a mandatory alcohol testing policy
â¢ Ensure processes are in place in the new electronic health record to alert affected staff and management when clinically significant changes are made to pathology reports.
â¢ Assess quality management processes related to external evaluations of non-HAV pathology consultants, a process that is encouraged and helps maintain high quality patient care standards for veterans, and the definition of procedures that ensure that parties concerned are informed of significant differences in interpretation that could affect patient care decisions.
â¢ Creation a quality analyst position at the VHSO dedicated to the pathology and laboratory medicine department.
â¢ Increasing monthly monitoring and reporting by VHSO’s pathology and laboratory medicine departments to the Medical Executive Board, the VA’s governing body for all clinical departments, to prevent future fraudulent documentation by any pathology and laboratory employee and ensure the integrity of information provided to governing or accreditation bodies such as the College of American Pathologists or the Joint Commission.