Urology Cancer Patients Faced Neglect at Arizona VA Hospital

An inspection conducted by the VA Office of Inspector General Office of Healthcare Inspections (OHI) at the Phoenix VA Health Care System identified issues related to patient access to care as well as quality of care issues at the hospital’s Urologic clinic, whcih could have resulted in adverse heath outcomes and even death for veterans with bladder and prostate cancer.

Following a preliminary review that identified staff shortages affecting thousands of patients, the OHI conducted a more exhaustive review of 3321 electronic medical records of patients referred to the clinic. About 45% of the patients experienced delays in getting new evaluations or follow-up appointments within the urology service. Additionally, 23% of the reviewed records care providers at the VA did not have timely access to patient medical records generated outside of the VA. The report interprets this as a lack of accurate data on the clinical status of these patients, indicating disconnected patient management.

Additionally, the investigation found that patients did not receive care or timely urological services to patients who needed care. Ten patients, the report says, experienced significant delays that could have affected their clinical outcome and placed the patient in the path of unnecessary harm.

The report urged the facility director at the hospital to make changes that would ensure adequate resources for timely patient care, provider access to patient records generated outside the VA system, and a review of cases that were identified as having received poor quality of care and a plan for adequate disclosure to patients and their families.

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