The Philadelphia VA Medical Center violated eight federal regulations on the use of radioactive materials in substandard treatments of nearly 100 veterans with prostate cancer, federal nuclear inspectors found after more than a year-long investigation.
Besides problems in its treatment of veterans with radioactive seed implants, the Philadelphia VA's response "lacked the rigor and formality required to demonstrate the licensees commitment to performance improvements," the U.S. Nuclear Regulatory Commission found.
The 16-page "inspection report" noted that after the VA determined it had given incorrect radiation doses to 98 out of 114 prostate cancer patients treated over six years, the hospital provided sloppy and inconsistent data about the cases to the NRC. In fact the VA double counted one patient and the actual number of veterans who got incorrect doses was 97.
Not until last month - more than year after the last of the substandard cases were identified - did the VA finally provide a comprehensive list of the radiation overdoses and underdoses delivered to the patients' prostates and nearby organs.
The head of the NRC's region III office in Lisle, Ill. near Chicago said in a statement that the report was the result of "comprehensive special inspection" into the program at Philadelphia VA.
"We discovered an absence of safety checks and balances . . . [that] must be in place to ensure safe and quality care for patients," said Mark Satorius, regional administrator.
"The NRC expects licensees who use nuclear materials in medicine to do so responsibly," he said. "We hope learning from this experience will prevent such egregious errors in the future."
The summary is a prelude to a Dec. 17 public meeting at which the NRC, which oversees the medical use of radiation, will decide what official action, if any, to take against the VA.
Richard S. Citron, Philadelphia VAMC Director, said "Our Philadelphia VA staff discovered and self-reported this situation 18 months ago. Since then, our primary focus has been on our Veterans – keeping them informed, providing the necessary follow-up care, and guiding them through the process to file administrative claims."
"While we cannot comment on the specifics of the report without reviewing it more fully, we will be fully prepared for the pre-decisional conference in December," Citron said.
"I want our staff, Veterans and families to rest assured that this difficult situation does not reflect the level of world-class care provided at the Philadelphia VA," Citron said. "Our dedicated employees provided care to more than 50,000 Veterans this year, and our Veterans and their families can be confident that their health care is second to none."
|
|
|
|
|
|
MOST POPULAR PHILLY.COM PHOTOS
NEWS
Philly.com Promotions
