Showing posts with label brachytherapy; few penalties; unplugged computer; Prostate; Radiation; Philadelphia; Nuclear Regulatory Commission;. Show all posts
Showing posts with label brachytherapy; few penalties; unplugged computer; Prostate; Radiation; Philadelphia; Nuclear Regulatory Commission;. Show all posts

Wednesday, November 18, 2009

Nuclear Regulatory Commission Report Finds Violations at Philadelphia-VA

Full Article at: NRC cites VA clinic for radioactive-treatment violations

By Josh Goldstein and Marie McCullough

Inquirer Staff Writers

"In the first outside report on its flawed prostate-cancer program, the Philadelphia VA Medical Center was cited for eight apparent violations in using radioactive materials on nearly 100 veterans, federal inspectors have concluded.

The Nuclear Regulatory Commission found that the Philadelphia VA staff failed to evaluate radiation doses or know when to report a mistake, according to the 16-page report obtained yesterday by The Inquirer.

The brachytherapy team, for example, failed to check radiation doses for more than a year because a computer was unplugged from the hospital's network, the report said.

The response to correct the problem was also flawed, the report found. The VA hospital, for example, double-counted one patient, and the true number of veterans who got incorrect radiation doses was 97, not 98 as originally reported."

Monday, November 16, 2009

Philadelphia-VA Medical Errors Bring Few Penalties

This lack of accountability is one of the main reasons that the VA system is in the shape that it is.

Full Article at: VA clinic troubles bring few penalties
Despite poor care in the Phila. prostate program, the agency has only slapped a few hands.

By Josh Goldstein

Inquirer Staff Writer

"More than a year after the Philadelphia VA Medical Center said it had given substandard care to nearly 100 veterans with prostate cancer, the list of sanctions is sparse:

One physician accepted a three-day suspension. A radiation safety official got a letter of reprimand. And the University of Pennsylvania doctor who performed most of the poor procedures lost his job when the Philadelphia VA closed the program.

Several lawmakers who have investigated the cases said that the Department of Veterans Affairs' actions were both anemic and late, and that the agency had acted only after prominent newspaper articles appeared in the summer, detailing radiation overdoses and underdoses.

"They ought not have to wait for a front-page newspaper article or a Senate committee hearing to do what they should have done on their own," said Sen. Arlen Specter (D., Pa.), one of the lawmakers who feels the VA has been slow to respond. "I think that it is regrettably necessary to keep pressure on them to follow up."

Newly obtained documents shed more light on the program, showing that the mistakes began with the earliest cases, starting in 2002, and that the hospital missed numerous opportunities to catch them.

In one 2003 case, for example, more than half the radioactive seeds landed in the patient's bladder instead of in the prostate. Yet no program-wide review ensued, and the brachytherapy treatments continued for five more years.

Gary Kao, the Penn radiation oncologist who directed the program, has been the public whipping boy for its flaws. He lost his VA position when the program was closed but was never officially sanctioned by the hospital. He's now on leave from Penn."