The University of Pennsylvania Hospital's prostate cancer brachytherapy treatment program has again come under fire following publication of a report filed by the 718-bed hospital indicating that radioactive seeds used to treat cancer had been implanted in the wrong area of a patient's body.
Hospital reports error with radioactive seeds
The report, filed on Feb. 25 with the Pennsylvania Environmental Protection Department, said a patient was implanted with 65 radioactive seeds on Jan. 21 as treatment for prostate cancer. On Feb. 23, during a follow-up CT scan, doctors discovered the seeds had been implanted in the wrong area, according to the report. Hospital officials said a malfunctioning new ultrasound machine used to guide placement of the seeds may have caused the mistake.
In response to the most recent event, the state agency has issued a recommendation notice to approximately 750 medical facilities that perform advanced radiology procedures. The notice advised providers to re-evaluate radiology equipment calibrations, develop and adhere to proper protocol and ensure appropriate training for radiology staff. The hospital reported the case to the state environmental agency and is cooperating fully with the agency, and an on-site review is being planned, according to Susan Phillips, senior vice president of public affairs.
Acknowledgement of the error comes as the University of Pennsylvania Hospital's brachytherapy program is undergoing an investigation by the state agency in conjunction with mistakes made during treatment of prostate cancer patients at the Philadelphia Veterans Affairs Medical Center between 2002 and 2008. The program, which has since been shut down, was run by University of Pennsylvania Hospital physicians.
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