Healthcare Inspection - Review of a Patient with Pulmonary Embolism Oklahoma City VA Medical Center, Oklahoma City, Oklahoma

We 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 or that the patient was given a diagnosis of lung cancer. We found that providers did not adequately pursue a possible diagnosis of pulmonary embolism at initial presentation or upon admission to the facility. 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.