V.A. Is Fined Over Errors in Radiation at Hospital

Posted on Mar 25, 2010 in Uncategorized


Published: March 17, 2010

The Nuclear Regulatory Commission on Wednesday announced its second-largest fine ever against a medical institution — $227,500 — after finding that the veterans hospital in Philadelphia had caused an “unprecedented number” of radiation errors in treating prostate cancer patients.

N.R.C. fines for medical errors involving radiation rarely exceed several thousand dollars. But commission officials said the size of the fine was justified by the magnitude of the failure at the hospital.

Federal investigators said the hospital made significant errors, misplacing radioactive seeds, in 97 of 116 procedures involving patients with prostate cancer from 2002 to 2008.

“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,” said Mark Satorius, a regional administrator for the commission, which regulates the use of nuclear isotopes in medical treatment.

Richard Citron, director of the Philadelphia Veterans Affairs Medical Center, acknowledged that there had been shortcomings in its oversight when the mistakes occurred. But he added, “The fact remains that our V.A. staff self-discovered these potential dosing issues almost two years ago, closed the program, self-reported to the N.R.C., cooperated fully with multiple investigations and have been transparent throughout the entire process.”

The fine was levied against the hospital’s parent agency, the Department of Veterans Affairs. According to the commission, the veterans agency has been reluctant to acknowledge all the errors. While it initially concurred with the commission’s findings, it has since changed its position, disputing both the nuclear agency’s definition of a medical error and the number of mistakes at the Philadelphia hospital, said Viktoria Mitlyng, a spokeswoman for the commission.

“They thought they could retract the events,” but they cannot, she said. However, the Department of Veterans Affairs can still challenge the proposed fine.

The regulatory commission’s largest fine against a medical provider was 15 years ago and totaled $280,000. That case also involved radiation errors.

The full scope of the problems at the Philadelphia hospital was first reported in June by The New York Times. The Times found that one radiation oncologist, Dr. Gary D. Kao, had been responsible for the great majority of the mistakes.

Dr. Kao no longer works at the hospital.

“V.A. officials can’t comment on specific actions taken against specific people,” Katie Roberts, a spokeswoman for the department, said Wednesday. “However, we can confirm that actions have indeed been taken, while additional actions are still in progress.”

A version of this article appeared in print on March 18, 2010, on page A20 of the New York edition.