Cancer treatment errors discovered at Philadelphia VA hospital

The New York Times reports on serious trouble with a cancer care unit at a Philadelphia Veterans Affairs medical center. The unit is under investigation after it apparently performed erroneous procedures for years:

Had the government responded more aggressively, it might have uncovered a rogue cancer unit at the hospital, one that operated with virtually no outside scrutiny and botched 92 of 116 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.

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.

Numerous factors contributed to this, including computer/equipment problems:

From December 2006 to November 2007, the nuclear commission found, 16 patients received seed implants in Philadelphia even though computer interface problems prevented medical personnel from determining whether those treatments had been successful.

The Philadelphia Inquirer cites the Nuclear Regulatory Commission finding several problems:

The NRC probe cited several causes, including that no corrective action was taken when low doses were discovered following procedures. Often, however, no such post-implant checks were performed because of a computer glitch. There was also inadequate supervision of the physician involved in the procedures, the VA’s root-cause analysis into the problems revealed.

It will be interesting to keep track as the investigations proceed to see what really happened and what exact mixture of human and technological factors resulted in the unfortunate outcomes.