Probe faults VA facility in radiation dosing

An investigation by the Veterans Affairs inspector general's office has found that the Philadelphia VA Medical Center failed to implement quality-management processes that could have prevented radiation under-dosing and overdosing among 114 prostate cancer patients treated at the center between 2002 and 2008.

The investigation, launched in July 2009 and concluded in March 2010, was prompted by a series of news reports and subsequent congressional hearings into reported cases of wrong dosing of prostate cancer patients being treated with brachytherapy at the center. At the time, the center had contracted with University of Pennsylvania physicians to provide the radiation services.

Among the findings detailed in a report released Monday is that medical center officials initiated no peer reviews or quality assessments of the brachytherapy program between 2002 and 2006. In addition, minor computer problems resulted in patients not receiving dosing studies during the five-year period. Investigators also noted that the medical center allowed University of Pennsylvania doctors to continue treating patients even after the contract between the two organizations had expired.

Despite such lapses, the VA inspector general found that the medical center's patient outcomes and death rates were in line within normal range. The agency made several recommendations, however, including having the Veterans Health Administration standardize quality control protocol, evaluate brachytherapy patients to assess the appropriateness of their treatment plans and review medical-service contracting protocol.