The Washington, DC, VA Medical Center didn't adequately notify women of their mammography results, including several exams with abnormal findings, according to an investigation by the U.S. Veteran's Administration's Office of the Inspector General (OIG).
The request for the inspection came from members of Congress, according to the OIG. It found the following:
- The medical center was not in compliance with Veterans Health Administration exam-result communication policy and women who had undergone breast imaging had not received results from their mammography exams.
- On discovery of the unsent result letters, facility staff informed all patients of any abnormal findings.
- Nine additional mammography exams had not been reviewed due to diagnostic coding errors; these additional exams were reviewed and determined to be normal.
- The medical center identified two patients and the OIG found two patients who had mammography exams that indicated breast cancer. All four of these patients did not receive timely letters regarding these results from the facility's imaging department but did receive notification of these results from their ordering physician.
- Referring physicians did not consistently document whether patients had been notified of abnormal mammography results.
- The facility did not have a "functional mammography program due to loss of staff."
- The medical center had not put into place recommendations from a September 2019 National Radiology Program Office (NRPO) site visit, including oversight of staff duties and training, quality controls regarding patient exam result letters, and development of a training program for mammography staff to track and monitor patients.
As a result of the investigation, the OIG made seven recommendations to the center, requesting it review and reestablish breast imaging documentation and notification processes, action plans, standard operating procedures, staff training, and NRPO reviews and requirements, it said.
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