Ft. Wayne-VA Medical concerns Substantiated, VAOIG Report 10-02810-139

"We substantiated that there were delays in notification of the patient’s test results and diagnosis of MG, with missed opportunities for follow-up care. We substantiated that a delay in diagnosis and treatment may have led to multiple ED visits and a subsequent hospital admission. We substantiated that a provider prescribed an antibiotic that exacerbated the patient’s MG."

Link to PRF full report at: Healthcare Inspection Quality of Care Issues VA Northern Indiana Health Care System, Ft. Wayne, Indiana

Report Number 10-02810-139, 3/31/2011 | Full Report (PDF)

The purpose of this review was to determine the validity of allegations regarding quality of care and delay in treatment of a patient at the VA Northern Indiana Health Care System, Fort Wayne, Indiana. A complainant alleged that there was a delay in notification of test results, diagnosis, and treatment, which may have led to multiple emergency department (ED) visits and a subsequent hospital admission. The complainant also alleged that his complaints of infection were ignored and that a medication was prescribed that exacerbated his Myasthenia Gravis (MG), a disease which affects the connection between muscles and nerves). Additional allegations included a breach in aseptic technique during intravenous therapy and delays in access to primary care. We substantiated that there were delays in notification of the patient’s test results and diagnosis of MG, with missed opportunities for follow-up care. We substantiated that a delay in diagnosis and treatment may have led to multiple ED visits and a subsequent hospital admission. We substantiated that a provider prescribed an antibiotic that exacerbated the patient’s MG. We did not substantiate that the patient’s complaints of infection were ignored. We could neither confirm nor refute that nurses did not use aseptic technique when connecting intravenous tubing or that there were significant delays in access to primary care.

We recommended that the system complete an external peer review for the appropriateness of care.