Sunday, July 19, 2009

Prostate Radiation Errors, Unplugged Computer Emblamatic of the Problem

"The unplugged computer was emblematic of the disconnection and disregard that investigators say pervaded the brachytherapy program at the Philadelphia VA."

"For a year, starting in November 2006, the computer workstation with the software used to calculate the post-implant dosages was unplugged from the hospital's network.

All that time, no one took steps to plug it back in, work around it, or tell patient-safety officials, investigators found.

As a result, post-implant calculations weren't performed during that period for Armstrong and 15 other patients, according to the U.S. Nuclear Regulatory Commission, which oversees medical use of radiation.

Even after the computer was finally reconnected to the network, investigators discovered, post-implant calculations continued to be omitted for an additional seven patients.

"The standard of care is that you do post-implant dosimetry in every case. There's never an excuse for not doing it," said radiation oncologist Gregory Merrick of Wheeling, W. Va., author of a textbook on brachytherapy. "Most institutions will not allow you to continue doing procedures if you have no quality assurance.""

Full Article: VA radiation errors laid to offline computer

By Marie McCullough and Josh Goldstein
Philly.com
Inquirer Staff Writers