The VA OIG reviewed an initial complaint regarding patient care and system responses at the hospital before opening an inquiry to determine the cause of delays. The delays included the failure of healthcare providers to accept or acknowledge exam alerts and to update the system's communication of test results policy, as well as a manager's failure to conduct a required peer review, the agency said.
Healthcare providers did not communicate test results that required follow-up within seven days, and radiologists did not undergo training for new national diagnostic codes or for software that generates view alerts, the OIG said. As well, the hospital should have completed an administrative inquiry, and it failed to identify a patient incident that necessitated a peer review.
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