FAYETTEVILLE, Ark. — A former pathologist and pathology and laboratory director who who was often drunk while on duty made mistakes in about 10% of the 34,000 cases he reviewed over 13 years, and the errors went unnoticed because this pathologist essentially policed himself when looking out for mistakes in his department.
That was one of a number of findings in a 102-page report, released on Wednesday by the Veterans Administration Office of Inspector General, on the Veterans Health Care System of the Ozarks in the case of convicted Dr. Robert Levy.
Levy, who headed pathology and laboratory medicine services until his removal in July 2018, pleaded guilty in federal court in 2020 to charges of involuntary manslaughter and mail fraud and was sentenced in January 2021 to 20 years in prison followed by three years of supervised release. He was also ordered to pay $498,000 in restitution to the VA.
Levy’s attorney filed a notice to appeal soon after his sentencing.
The report cited numerous reports of Levy appearing to be drunk on the job, especially from 2014-16, and his attempts to cover up alcohol abuse by taking a chemical that enables a person to get drunk but makes the alcohol undetectable in normal drug and alcohol testing.
The report said Levy had a problem with alcohol dating back 30 years.
Mistakes and consequences
The inspector general’s report said the 3,000 mistakes included 589 “major diagnostic discrepancies interpreted during his time at the facility.”
“Two examples of patients who had major diagnostic discrepancies illustrate the fatal consequences of Dr. Levy’s actions,” the report said. “One patient underwent a prostate biopsy in 2012 that Dr. Levy reported to be benign. Look-back reviewers in 2018 identified cancer in two of the six biopsy specimens. At the time the patient was notified of the cancer diagnosis in 2018, treatment was limited to palliative care. The patient died in late 2020.
“A second patient was treated for small-cell cancer after Dr. Levy made the diagnosis in 2014. The patient died about a year later. The look-back review determined that the patient had squamous cell cancer of the lung, not small-cell cancer. Treatment options for squamous cell cancer included surgery, which was not offered to the patient.”
The inspector general’s report says the “enormous number of serious diagnostic errors” by Levy was the result of Levy’s failure to interpret the specimens correctly.
But the mistakes remained undetected for years in part “because of his manipulation of the pathology quality management data and deficiencies in quality management processes.”
The VA declined to answer specific questions about the report and released a prepared statement in response to requests for comment.
“The Veterans Health Care System of the Ozarks (VHSO) and the Department of Veterans Affairs is truly saddened at the pain victims and families endured at the hands of this pathologist,” the statement said. “The department assures veterans that we are fully committed to improving our processes and systems moving forward to prevent a situation like this from happening again. VA has begun the process of addressing many of the OIG’s recommendations and expects to complete the remainder by May 2022.”
The report said administrators at the Fayetteville hospital failed to protect patients when staff members at the hospital reported signs that Levy was under the influence of alcohol in 2014-16.
The report talks about four cases where staff reported Levy for “smelling like alcohol” or having red eyes or hand tremors, one in 2014, two in 2015 and one in 2016.
The report also says Levy disclosed a 1996 conviction related to driving while intoxicated when he was hired in 2005 and admitted to a 30-year problem with alcoholism.
After the 2016 report, Levy was “removed from clinical care,” but he was allowed to return to work in October 2016 after completing a treatment program.
“Had facility leaders taken the opportunities that presented as early as March 2014 to vigorously address allegations of impairment and adequately review Dr. Levy’s clinical competency, his removal may have occurred sooner,” the report said. “An extensive review of Dr. Levy’s cases and assessment of his competency prior to reinstatement in 2016 would likely have revealed results similar to the look-back review and may have averted the facility’s decision to return Dr. Levy to clinical practice. The chief of staff informed the OIG that the lack of evidence of patient adverse clinical outcomes factored into the decision that allowed Dr. Levy to return to clinical service in October 2016.”
The inspector general’s report cited a failure to “foster a culture of accountability” in the process that allowed Levy to continue to work with patients despite the reports of problems.
“While the OIG recognizes that impaired providers should be offered assistance in appropriate situations, senior leaders missed opportunities to address Dr. Levy’s impairment,” the report said. “The OIG found a culture in which staff did not report serious concerns about Dr. Levy in part, because of a perception that others had reported or they were concerned about reprisal. Any one of these breakdowns could cause harmful results. Occurring together and over an extended period of time, the consequences were devastating, tragic, and deadly.”
In its written response, the VA said it has changed the processes at the Veterans Health Care System of the Ozarks and nationally to prevent care providers from causing harm to patients.
The statement said the administration has “strengthened internal controls by ensuring no provider can review his or her own work and by providing more stringent oversight, policy and processes.”
It listed six specific changes to policies and processes:
• Implementing a VA-wide policy requiring facilities with two or fewer providers in any given specialty to have provider reviews performed at an alternate VA facility with similarly qualified specialty providers, ensuring independent and objective oversight.
• Evaluating current guidance related to impaired health care workers and exploring the possibility of a mandatory alcohol testing policy.
• Ensuring processes are in place in the new electronic health record to alert relevant staff and leadership when clinically significant changes to pathology reports are made.
• Evaluating quality management processes related to external, non-VHA pathology consultant assessments, a process that is encouraged and helps maintain high quality patient care standards for veterans, and defining procedures that ensure relevant parties are notified of significant discrepancies in interpretation that might affect patient care decisions.
• Creating a quality analyst position at VHSO dedicated to pathology and laboratory medicine service.
• Increasing oversight and monthly reporting by VHSO Pathology and Laboratory Medicine services to the Medical Executive Council, VA’s governing body for all clinical services, to prevent future fraudulent documentation by any pathology and laboratory employees and ensure the integrity of information provided to governing or accrediting bodies such as the College of American Pathologists or The Joint Commission.