Mental HealthAt Veterans Affairs Hospital, A Rogue Cancer Unit
The New York Times reports that a "rogue cancer unit" at a veteran"s hospital in Philadelphia "operated with virtually no outside scrutiny and botched 92 of 116 [prostate] cancer treatments over a span of more than six years - and then kept quiet about it, according to interviews with investigators, government officials and public records." Dr. Gary D. Kao-- was responsible for almost all of the errors, which occurred during a "common surgical procedure" in which a doctor "implants dozens of radioactive seeds to attack the prostate cancer. "The team continued implants for a year even though the equipment that measured whether patients received the proper radiation dose was broken. The radiation safety committee at the Veterans Affairs hospital knew of this problem but took no action, records show." The cancer unit lacked peer review, and "the VA"s radiation safety program; the Nuclear Regulatory Commission, which regulates the use of all nuclear materials; and the Joint Commission, a group that accredited the hospital, all failed to intervene; either their inspections had been limited or they had not acted decisively upon finding problems."
"Federal investigators are continuing to look into the flawed implants as well as those at other VA hospitals. The Philadelphia prostate unit was closed after problems began to surface in mid-2008, and it has yet to reopen. The VA has also suspended the implants, known as brachytherapy, at hospitals in Jackson, Miss., and Cincinnati, though neither had problems on a scale of Philadelphia"s" (Bogdanich, 6/20).
The Philadelphia Inquirer: "Why did it take more than six years to catch the errors? One reason could be a lack of independent oversight, said James P. Bagian, chief patient-safety officer for the VA health system. Bagian, who cochaired a systemwide review of brachytherapy last fall, said his committee found that in Philadelphia and other VA medical centers, the quality-assurance aspects of the programs were conducted by the contracted doctors themselves and were not "independent enough to assure we are getting an unbiased report"" (Goldstein, 6/21).
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