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PHILADELPHIA — The Department of Veterans Affairs was fined $227,500 after incorrect radiation doses were given to 97 veterans with prostate cancer at the Philadelphia VA Medical Center, a federal agency announced Wednesday.
The Nuclear Regulatory Commission said the fine is the second largest it has ever levied for medical errors. The VA was cited for lacking procedures to ensure and verify the treatments were done correctly, failing to properly train staff and neglecting to immediately report mistakes.
"This substantial fine emphasizes the high significance of violations at the Philadelphia Veterans Affairs Medical Center that resulted in close to 100 of our nation's veterans receiving substandard treatments," NRC regional administrator Mark Satorius said.
The men underwent brachytherapy, a common surgical treatment that involves implanting tiny radioactive iodine pellets, often called "seeds," in the prostate to kill cancer cells. Men who undergo only that type of treatment typically have low-risk prostate cancer.
VA officials reviewed medical records and conducted tests on 116 veterans implanted with the seeds from 2002 to 2008 and found that 97 received the wrong doses. Most of the men got far less than the prescribed dose, while others received too much radiation to nearby tissue and organs.
"The 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," Satorius said in a statement.
The Philadelphia VA Medical Center, established in 1952, shut down its prostate cancer program as a result of the botched treatments.
The Department of Veterans Affairs has 30 days to pay the fine or challenge it.
Richard Citron, director of the medical center, acknowledged that "there were clearly missed opportunities in oversight from 2002 to 2008." He added that it was the VA that discovered the errors, closed the program, reported its findings to the NRC and cooperated with the investigations that followed.
"I am troubled anytime my fellow veterans may not receive the level of care they earned and deserve," Citron said. "But issues with the brachytherapy program do not reflect the high level of health care offered in Philadelphia or throughout the VA system."
The highest fine ever imposed by the NRC was $280,000 in separate cases in 1987 and 1994.
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On the Net:
Philadelphia Veterans Affairs Medical Center: http://www.philadelphia.va.gov
Nuclear Regulatory Commission: http://www.nrc.gov
