Nearly two years after medical errors at the Philadelphia Veterans Affairs Medical Center came to light, which involved 97 of 116 prostate cancer treatments being performed incorrectly, the Nuclear Regulatory Commission announced its second biggest fine ever against a medical facility. The NRC on Wednesday proposed a $227,500 fine against the Department of Veterans Affairs, the parent of the Philadelphia hospital.
The incorrect procedures, performed between 2002 and 2008, involved iodine-125 seeds to treat prostate cancer not only being placed in "unintended organs and tissues," but also being used in "inconsistent" doses, according to an NRC inspection report from November 2009. As a result, some patients experienced "radiation proctitis, rectal bleeding...from high doses of radiation, and recurrences of cancer." Five of the 114 overall patients treated (two were treated twice) died, but not as a result of the treatments, according to the report.
Furthermore, many of the incorrect procedures initially went unreported.
"This lack of management oversight, the lack of safety culture to ensure patients are treated safely, the potential consequences to the veterans who came to this facility and the sheer number of medical events show the gravity of these violations," said Mark Satorius, regional administrator for the NRC's Region III office.
Despite the fine, the VA insists that it has taken all the right steps in dealing with this situation, according to the New York Times. Not only was the VA Philadelphia prostate cancer treatment program indefinitely suspended, but the physician responsible for a majority of the incorrect treatments, Dr. Gary Kao, is no longer employed at that facility.
"The fact remains that our VA staff self-discovered these potential dosing issues almost two years ago...cooperated fully with multiple investigations and have been transparent throughout the entire process," said Richard Citron, director of the Philadelphia VA facility.