Department of Veterans Affairs
 

Office of Inspector General
 

Healthcare Inspection
 

Review of a Patient with Pulmonary
 

Embolism
 

Oklahoma City VA Medical Center
 

Oklahoma City, Oklahoma
 

Report No. 11-02385-300 September 30, 2011
 VA Office of Inspector General
 

Washington, DC 20420
 
To Report Suspected Wrongdoing in VA Programs and Operations:
 

Telephone: 1-800-488-8244
 

E-Mail: vaoighotline@va.gov
 

(Hotline Information: http://www.va.gov/oig/contacts/hotline.asp)
 
Review of a Patient with Pulmonary Embolism, Oklahoma City VAMC, Oklahoma City, OK 

Executive Summary
 

The VA Office of Inspector General Office of Healthcare Inspections conducted a review 

to determine the validity of allegations of misdiagnosis by providers at the Oklahoma 

City VA Medical Center (facility) in Oklahoma City, OK. The complainant alleged that: 

	 A patient was given a diagnosis of communicable pneumonia and then placed in a 

room with four other patients in the facility’s emergency room. 

	 The patient was incorrectly given a diagnosis of lung cancer. 

	 When the patient left the facility and went to a community hospital, the patient 

was found to have acute pulmonary embolism. 

We did not substantiate that the patient was placed in a room with four other patients. 

The facility’s emergency room cannot accommodate more than two patients in a room, 

but the patient may have been evaluated in areas where other patients were nearby and 

management of patients with pneumonia does not require isolation. 

We did not substantiate that the patient was given a diagnosis of lung cancer. The 

providers we interviewed denied giving the patient a diagnosis of lung cancer. However, 

providers did document that malignancy was a diagnostic consideration, and that 

possibility may have been mentioned to the patient. 

We found that providers did not adequately pursue a possible diagnosis of pulmonary 

embolism at initial presentation or upon admission to the facility. This patient had 

previously been treated for pulmonary embolism and recurrence might have been 

prevented. 

We recommended that the Facility Director obtain a peer review assessment of the care 

provided to this patient during both presentations to the emergency room and subsequent 

admission. 

The Veterans Integrated Service Network and Facility Directors concurred with our 

findings. We will follow up until the planned actions are completed. 

VA Office of Inspector General i 
DEPARTMENT OF VETERANS AFFAIRS
 

Office of Inspector General
 

Washington, DC 20420
 

TO:	 Director, South Central VA Health Care Network (10N16) 

SUBJECT:	 Healthcare Inspection – Review of a Patient with Pulmonary Embolism, 

Oklahoma City VA Medical Center, Oklahoma City, Oklahoma 

Purpose 

The VA Office of Inspector General (OIG) Office of Healthcare Inspections reviewed 

allegations of misdiagnosis by providers at the Oklahoma City VA Medical Center, 

(facility) in Oklahoma City, OK. The purpose of the inspection was to determine if the 

allegations had merit. 

Background 

The facility is a 159-bed tertiary care facility that provides comprehensive healthcare 

through inpatient and outpatient services in medicine, surgery, mental health, and 

rehabilitation medicine. The facility is part of Veterans Integrated Service Network 16. 

In April 2011 a complainant contacted OIG’s Hotline Division regarding patient care 

concerns and alleged misdiagnosis at the facility. The complainant alleged that: 

	 A patient was given a diagnosis of communicable pneumonia and then placed in a 

room with four other patients in the facility’s Emergency Room (ER). 

	 On the second day of hospitalization, the patient was incorrectly given a diagnosis 

of lung cancer. 

	 When the patient left the facility and presented to a community hospital, the 

patient was found to have acute pulmonary embolism (PE).1 

Scope and Methodology 

We conducted telephone interviews with the patient and providers involved in the care of 

this patient during the review period. We reviewed the physical layout of the facility’s 

1 PE occurs when one or more arteries in the lungs become blocked, usually by blood clots that travel to the lungs 

from the legs. 

VA Office of Inspector General 1 
Review of a Patient with Pulmonary Embolism, Oklahoma City VAMC, Oklahoma City, OK 

ER. We reviewed the patient’s facility medical record, medical records from the 

community hospital admission, relevant facility policies, and relevant Veterans Health 

Administration directives. 

We conducted the inspection in accordance with Quality Standards for Inspection and 

Evaluation published by the Council of the Inspectors General on Integrity and 

Efficiency. 

Case Summary 

The patient was a man in his fifties with a history of impaired memory, depression, 

diabetes, high blood pressure, heart attacks, heart surgeries, degenerative joint disease, 

obstructive lung disease,2 and a stable lung nodule.3 Additionally, in 2006, deep vein 

thrombosis (DVT)4 and PE were diagnosed, and he was treated with warfarin5 until 

January 2010. 

In August 2010, the patient presented to the facility ER complaining of chest pain for 

2 days. He was diagnosed with pneumonia and discharged home on oral antibiotics. 

Discharge instructions included encouragement to quit smoking, instructions to contact 

his primary care provider in 4 days if not feeling better, and to return to the ER if his 

chest pain became worse or other symptoms occurred. 

Five days later, the patient reported feeling worse and was evaluated in the facility’s 

Urgent Care Clinic and transported to the ER. He was admitted to the facility with a 

diagnosis of right upper lobe pneumonia for treatment to include intravenous antibiotics. 

The patient’s inpatient provider documented lung sounds common to pneumonia and 

noted the patient’s complaint of a productive cough that caused chest wall tenderness. 

Because of concerns regarding possible malignancy or atypical infection, the provider 

ordered a computed tomography scan (CT) without contrast,6 noting that the patient’s 

creatinine7 level was elevated. The provider documented that a repeat CT with contrast 

would be ordered when the patient’s creatinine level improved. 

The CT report documented areas in the lungs “concerning for pneumonia” and that the 

patient’s longstanding lung nodule remained unchanged from prior imaging. The 

2 Obstructive lung disease refers to a group of conditions that cause difficulty breathing.
 3 A stable benign lung nodule is a small mass of tissue on the lung that has remained stable in size for more than
 

2 years and is not considered cancerous.

4 A blood clot in the leg is generally called a deep vein thrombosis.
 5 Warfarin is a medication that is used to treat or prevent clots in the veins, arteries, lungs, or heart.
 6 A CT uses x-rays to produce detailed pictures inside of the body. Contrast, or dye, may be injected or swallowed
 

by the patient to enhance the x-ray picture.

7 A creatinine test shows how well the kidneys function. High levels suggest that the kidneys might have trouble
 

clearing x-ray contrast from the body.
 

VA Office of Inspector General 2 
Review of a Patient with Pulmonary Embolism, Oklahoma City VAMC, Oklahoma City, OK 

patient’s creatinine level was noted as improving and vital signs were documented as 

stable. 

The provider documented breathing improvement despite a persistent cough and chest 

tenderness. Nurse’s notes documented no complaints of pain by the patient. During the 

evening of day three, a nurse documented the patient was agitated and refused 

medications, threatening to leave the facility. On day four, the patient refused any further 

treatment and left the hospital against medical advice. 

Three days later, the patient was admitted to a community hospital. The discharge 

summary from that hospitalization states “CT scan of the chest with infusion revealed 

moderate-sized pulmonary emboli identified within the branches to each lobe,” and lower 

extremity ultrasonography revealed DVT. 

Issue 1: Initial ER Care, Including Diagnosis and Room Placement 

We did not substantiate that the patient was held in an area with four other patients. 

The patient described being held in an ER storage or overflow area with four other 

patients. However, we found that the ER area consists of 12 exam rooms arranged in a 

semi-circle around the nurse’s station. There is no overflow or additional space where 

ER patients are placed. The space in the exam rooms is limited and cannot accommodate 

more than one or two patients. 

Facility policy requires spatial separation of patients with respiratory infections of greater 

than 3 feet in common waiting areas. Patients with pneumonia are not usually isolated. 

Issue 2: Diagnosis of Lung Cancer 

We did not substantiate that the patient was given a diagnosis of lung cancer. 

The patient stated that a provider discussed a diagnosis of lung cancer. However, none of 

the providers we interviewed recalled such a discussion and there is no documentation in 

the record to support that a discussion of a lung cancer diagnosis by any provider 

occurred. Providers did document that malignancy was a diagnostic consideration, and 

that possibility may have been mentioned to the patient. 

Issue 3: Diagnosis of Pulmonary Embolism 

We found that providers did not adequately pursue the diagnosis of PE. This patient has 

a past history of PE. Recurrent PE might have been prevented if providers had 

appropriately pursued the diagnosis at initial presentation or upon hospital admission. 

The patient was admitted to a community hospital 3 days after leaving the facility and 

found to have both PE and DVT. 

VA Office of Inspector General 3 
Review of a Patient with Pulmonary Embolism, Oklahoma City VAMC, Oklahoma City, OK 

While hospitalized at the facility, the patient was treated for community-acquired 

pneumonia, and pneumatic compression hose and low-dose anticoagulation were ordered. 

However, providers’ progress notes indicate no recognition that the patient’s prior history 

of DVT and PE conferred a risk of recurrence or that PE might be responsible for the 

patient’s symptoms. The patient had received outpatient anticoagulation during the 

previous year. Further, the patient’s most prominent presenting symptom of chest pain 

was out of proportion to his other symptoms and chest x-ray findings attributed to 

pneumonia. 

A chest CT scan was obtained on the second hospital day to evaluate the possibility of 

malignancy. However, intravenous contrast was not used because of the patient’s renal 

insufficiency. This diagnostic study was therefore inadequate to assess the possibility of 

PE, and in any case that possibility was not mentioned. 

Given the patient’s past history of PE and new symptoms including chest pain, providers 

should have pursued the possibility of acute PE on either occasion when he presented to 

the ER or when he was admitted to the facility. Various management strategies could 

have been considered for this patient, including lower extremity ultrasonography8 and 

immediate therapeutic anticoagulation with delay of contrast CT until after administration 

of intravenous fluids. 

Conclusions 

We did not substantiate that the patient was placed in a room with four other patients. 

The facility’s ER cannot accommodate more than two patients in a room, but the patient 

may have been evaluated in areas where other patients were nearby. Management of 

patients with pneumonia does not require isolation. 

We did not substantiate that the patient was given a diagnosis of lung cancer. The patient 

stated that a provider discussed a diagnosis of lung cancer; however, none of the 

providers we interviewed recalled such a discussion. Providers did document that 

malignancy was a diagnostic consideration, and that possibility may have been mentioned 

to the patient. 

We could not substantiate that providers failed to make the diagnosis of PE because it is 

impossible to know with certainty whether or not the patient had a PE when he was 

treated at the facility. Nevertheless, we did find that providers did not adequately pursue 

the diagnosis at initial presentation or upon admission to the facility. This patient had 

previously been treated for PE and recurrence might have been prevented. 

8 Lower extremity ultrasonography is a non- invasive procedure that uses high- frequency sound waves to check for 

blood clots in leg veins. 

VA Office of Inspector General 4 
Review of a Patient with Pulmonary Embolism, Oklahoma City VAMC, Oklahoma City, OK 

Recommendation 

Recommendation. We recommended that the Facility Director obtain a peer review 

assessment of the care provided to this patient during both presentations to the ER and 

during his subsequent admission. 

Comments 

The Veterans Integrated Service Network and Facility Directors concurred with our 

findings (See Appendixes A and B, pages 6-8, for the full text of their comments). We 

will follow up until the planned actions are completed. 

JOHN D. DAIGH, JR., M.D.
 

Assistant Inspector General for
 

Healthcare Inspections
 

VA Office of Inspector General 5 
Review of a Patient with Pulmonary Embolism, Oklahoma City VAMC, Oklahoma City, OK 

Appendix A 

Veterans Integrated Service Network Director Comments 

Department of 

Veterans Affairs Memorandum 

Date:	 September 1, 2011 

From:	 Director, South Central VA Health Care Network (10N16) 

Subject:	 Healthcare Inspection – Review of a Patient with Pulmonary 

Embolism, Oklahoma City VA Medical Center, Oklahoma City, 

Oklahoma 

To:	 Director, Dallas Office of Healthcare Inspections (54DA) 

Thru:	 Director, Veterans Healthcare Administration Management 

Review Service (10A4A4) 

I have reviewed the results of the Healthcare Inspection of the 

Oklahoma City VA Medical Center and concur with the 

findings. 

Thank you for this comprehensive review. 

(original signed by:) 

George H. Gray, Jr.
 

Director, South Central VA Health Care Network (10N16)
 

VA Office of Inspector General 6 
Review of a Patient with Pulmonary Embolism, Oklahoma City VAMC, Oklahoma City, OK 

Appendix B 

Facility Director Comments 

Department of 

Veterans Affairs Memorandum 

Date:	 August 29, 2011 

From:	 Director, Oklahoma City VA Medical Center (635/00) 

Subject:	 Healthcare Inspection – Review of a Patient with Pulmonary 

Embolism, Oklahoma City VA Medical Center, Oklahoma City, 

Oklahoma 

To:	 South Central VA Health Care Network (10N16) 

I concur with the findings of Healthcare Inspection review 

team. 

We appreciate the opportunity to work with the Office of Inspector 

General as we continuously strive to improve the quality of 

healthcare for America’s Veterans. 

David P. Wood, MHA, FACHE
 

Director, Oklahoma City VA Medical Center (635/00)
 

VA Office of Inspector General 7 
Review of a Patient with Pulmonary Embolism, Oklahoma City VAMC, Oklahoma City, OK 

Director’s Comments
 

to Office of Inspector General’s Report
 

The following Director’s comments are submitted in response to the 

recommendations in the Office of Inspector General’s report: 

OIG Recommendation 

Recommendation: We recommended that the Medical Center Director 

obtain a peer review assessment of the care provided to this patient during 

both presentations to the ER and subsequent admission. 

Concur Target Completion Date: September 10, 2011 

Facility’s Response: 

Peer reviews were requested in accordance with VHA Directive 2010-025 

to review the care provided to this patient in the ER and the inpatient 

admission. 

Status: Pending 

VA Office of Inspector General 8 
Review of a Patient with Pulmonary Embolism, Oklahoma City VAMC, Oklahoma City, OK 

Appendix C 

OIG Contact and Staff Acknowledgments 

OIG Contact	 For more information about this report, please contact the 

Office of Inspector General at (202) 461-4720. 

Acknowledgments	 Cathleen King, MHA, CRRN, Project Leader 

Maureen Washburn, ND, RN 

Jerome Herbers, MD, Medical Consultant 

Misti Kincaid, BS, Program Support Assistant 

VA Office of Inspector General 9 
Review of a Patient with Pulmonary Embolism, Oklahoma City VAMC, Oklahoma City, OK 

Appendix D 

Report Distribution 

VA Distribution 

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, South Central VA Health Care Network (10N16) 

Director, Oklahoma City VA Medical Center (635/00) 

Non-VA Distribution 

House Committee on Veterans’ Affairs 

House Appropriations Subcommittee on Military Construction, Veterans Affairs, and 

Related Agencies 

House Committee on Oversight and Government Reform 

Senate Committee on Veterans’ Affairs 

Senate Appropriations Subcommittee on Military Construction, Veterans Affairs, and 

Related Agencies 

Senate Committee on Homeland Security and Governmental Affairs 

National Veterans Service Organizations 

Government Accountability Office 

Office of Management and Budget 

US Senate: Tom Coburn, James M. Inhofe 

US House of Representatives: Dan Boren, Tom Cole, James Lankford, Frank Lucas, 

John Sullivan 

This report is available at http://www.va.gov/oig/publications/reports-list.asp. 

VA Office of Inspector General 10