Walt Bogdanich of The New York Times uncovered an astounding series of regulatory and oversight errors that allowed a “rogue” cancer unit operate with impunity at the Veterans Affairs Medical Center in Philadelphia.
Bogdanich reports that its doctors, primarily Dr. Gary Kao, had botched 92 of 116 cancer treatments in more than six years. The unit treated prostate cancer with radioactive implants, a process known as brachytherapy. Doctors in the unit avoided regulation in part by revising surgical plans to cover for mistakes.
The first clear signs of trouble cropped up in early 2003, the unit was suspended in 2008. Here’s a brief catalog of missed opportunities to reign in Johns Hopkins-trained Kao and associates:
- The unit did not have any peer review process in place.
- The V.A.’s radiation safety program didn’t intervene.
- Neither did the Joint Commission, the group that accredited the hospital.
- Doctors in the radiation implant program weren’t properly supervised.
- Or “trained in what constitutes a substandard implant and the need to report it.”
- Errors went unreported for months, or even years, while patients had no idea they were even made.
The whole house of cards only came tumbling down when a mistaken purchase of lower-radiation implants triggered an investigation of previous cases. Investigators didn’t find any lower-radiation implants, but they did find errors. Lots of them.
No patients are believed to have died from this mistake-riddled treatment; the unit was suspended in mid-2008 and similar programs (whose problems don’t seem to have been as severe) were shuttered in Jackson, Miss., and Cincinnati. Seven of the affected patients were flown to a more experienced V.A. unit for additional treatment.
Update
In a related story, The Philadelphia Inquirer reports that the problems came to light “not because the NRC finished its inquiry” but rather when a Nuclear Regulatory Commission advisory committee asked the agency for an update because “committee members had been hearing disturbing things about the Philadelphia VA’s program.”
