Inadequate Care by a Clinical Pharmacy Specialist and a Primary Care Provider at the Tennessee Valley Healthcare System in Nashville

The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate an allegation that a clinical pharmacy specialist (CPS) failed to act on a patient’s abnormal test results in fall 2018, which led to the patient going undiagnosed and untreated for pancreatic cancer for three months. The OIG determined that three months prior to the event, during an annual physical examination, a facility primary care provider failed to acknowledge or assess the patient’s unintentional weight loss. The OIG substantiated that the CPS failed to act on a patient’s abnormal test results and communicate those results to the patient. However, the OIG was unable to determine if immediate action by the CPS would have led to the patient receiving a prompt diagnosis and treatment for pancreatic cancer. The OIG found that the CPS also did not document a change in the patient’s plan of care. The current electronic health record used within the Veterans Health Administration (VHA) lacks a process to ensure that test results are communicated and acted upon by ordering providers. The OIG determined that facility policies and practices supported CPSs collaborating with primary care providers when a patient’s condition changed. Although the OIG found no evidence to indicate an overall lack of collaboration between providers and CPSs, in this case, the OIG determined that an opportunity for collaboration was missed. The OIG found that facility leaders provided oversight of patient care delivered by CPSs. The OIG made one recommendation to the Veterans Integrated Service Network Director to conduct a comprehensive review of the patient’s episode of care and take action as indicated. The OIG made one recommendation to the facility Director to ensure staff are aware of and follow the VHA directive regarding communication of test results.