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Multiple Failures in Test Results Follow-up for a Patient Diagnosed with Prostate Cancer at the Hampton VA Medical Center in Virginia.

Washington, DC: VA Office of the Inspector General; June 28, 2022. Report No 21-03349-186.

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July 13, 2022

Washington, DC: VA Office of the Inspector General; June 28, 2022. Report No 21-03349-186.

 Cancer test communication failures can contribute to physical, emotional, and financial patient harm. This report examines missed opportunities made by multiple clinicians involved in the care of a patient with prostate cancer who then died from metastasized disease Seven recommendations are included for improving abnormal test result communication and error management at the facility.