Pathology Oversight Failures at the Veterans Health Care System of the Ozarks in Fayetteville, Arkansas VA.

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Pathology Oversight Failures at the Veterans Health Care System of the Ozarks in Fayetteville, Arkansas VA.

June 16, 2021

Office of Inspector General. June 2, 2021. Report No. 18-02496-157.

Health systems can exacerbate potential risk for patient harm due to clinician impairment and unprofessional activities. This report examines a long-term situation that, due to failure of reporting and other system issues, enabled over 3,000 diagnostic delay injuries stemming from specimen errors associated with one pathologist.

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Facility and Group Administrators

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Pathology and Laboratory Medicine

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Culture of Safety

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