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Central Alabama VA lost 900 patient X-rays since 2009

MONTGOMERY, Ala. — At least 900 unread patient X-rays taken at Central Alabama Veterans Health Care System facilities since 2009 had been lost until recently, and top administrators who knew about the problem tried to cover it up, according to documents obtained by the Montgomery Advertiser.

Some of the lost X-rays showed possible malignancies and abnormalities that required medical attention.

More than 200 recent X-rays were found around April, not long after they were lost.

But when radiologists read the 654 older X-rays, some as old as five years, they found many showed problems needing medical attention.

Seven X-rays showed possible malignancies, one is abnormal, seven are considered major abnormalities, 119 are abnormal with attention needed, 25 are major abnormalities with no attention needed and 139 are minor abnormalities, according to an updated version of a May 1 CAVHCS Veterans Health Administration Issue Brief.

A study has not yet been done to determine the impact losing these X-rays had on patient health.

Staff began noticing in October 2012 that there was a problem with X-rays missing from the computer system, according to the original issue brief from May 1, which was modified on May 5 and July 8.

CAVHCS Director James Talton notified the VA's Southeast regional chief medical officer, who is in charge of VA systems in Alabama, Georgia and South Carolina, that unread imaging exams were intermittently falling off the "unread list" in the system, according to the brief.

Regional staff and administrators determined that there wasn't enough memory on radiologists' workstations, and the recommendation was to increase the memory, according to emailed documents provided to the Advertiser by unnamed VA officials who requested anonymity for fear of losing their jobs. However, X-rays continued to disappear off the unread list.

Anticipating a new radiology system that was supposed to be purchased for the whole region, CAVHCS did not pursue its own new system, the brief said.

On April 30 of this year, a provider couldn't find an X-ray for a patient and notified IT staff, who discovered that X-rays that haven't been read in the first eight days "fall off" the system, according to the brief.

On May 1, the staff member changed the settings from eight days to five years, and about 900 unread X-ray exams showed up on the list, the brief said.

The current brief includes no indication of the problems that occurred between October 2012 and April 2014.

A May 6 email from Stephen Holt, the regional chief medical officer, said the May 5 version of the brief needed a substantial rewrite before it could be passed along, and asked that all the references to 2012 be taken out. The brief also indicates that clinical and institutional disclosure of the problem was not needed.

The email said the reference to workstation issues in 2012 is "unrelated and begs unnecessary and unrelated questions."

The final version, dated July 8, was sent to the regional office in Atlanta on Wednesday, according to emails obtained by the Advertiser. It doesn't contain any references to the problems in 2012 and does not indicate that any CAVHCS staff knew about the problem until April 2014.

The modified brief also recommends a root cause analysis review, which is a blame-free patient safety mechanism to identify process issues that contributed to a problem. However, the brief issue form doesn't have anything checked off on whether disclosure is needed.

According to the final version of the brief, CAVHCS will be working with other facilities in Birmingham, Columbia, S.C., and Charleston, S.C., to establish a network so each facility can access and interpret X-rays. CAVHCS has also hired two radiologists, one of which will start next week, according to the brief.

An email Holt sent Thursday shows that the next step is to conduct clinical reviews to see whether the delayed readings affected patients. Staff members are also trying to find X-rays older than five years that might not have been read.

Attempts to reach Holt and Talton were unsuccessful Thursday.
 

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