NRC: News Release - Region III - 2008-033 - NRC Begins Special Inspection of the Department of Veterans Affairs Due to Multiple Medical Events

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NRC NEWS
U.S. NUCLEAR REGULATORY COMMISSION

Office of Public Affairs, Region III
2443 Warrenville Road, Lisle, IL 60532
www.nrc.gov

No. III-08-033		Sepember 9, 2008
CONTACT:	Viktoria Mitlyng (630) 829-9662	E-mail: opa3@nrc.gov
NRC BEGINS SPECIAL INSPECTION OF THE DEPARTMENT OF VETERANS AFFAIRS DUE TO MULTIPLE MEDICAL EVENTS Printable Version
The Nuclear Regulatory Commission is conducting a special inspection at the Veterans Affairs Medical Center in Philadelphia, PA, to examine the circumstances surrounding multiple underdoses during radiation treatments of prostate cancer that occurred between February 2002 and June 2008. On May 18, 2008, the Department of Veterans Affairs National Health Physics Program notified the Nuclear Regulatory Commission that the radiation dose delivered to a patient at the Veterans Affairs Medical Center in Philadelphia, PA, to treat prostate cancer was more than 20 percent lower than the prescribed dose. The treatment involved implanting iodine-125 seeds of a prescribed radiation dose into the patient’s prostate. During the event on May 5, iodine-125 seeds used in the procedure were of incorrect radiation dose. The National Health Physics Program conducted an inspection in May and June of this year in response to the May 5 event. In all, 112 procedures that took place since the inception of the cancer treatment program in Feb. 2002 were reviewed. Fifty-five of these cases were identified as medical events that involved administering an incorrect radiation dose to a patient. As a result of the review, the VA Medical Center suspended its prostate cancer treatment program in June 2008. The Medical Center is reviewing possible effects on patients. Circumstances for each patient are being evaluated to determine if follow-up medical care is needed. NRC Region III conducted a reactive inspection at the Medical Center in July of this year. Based on the results of this inspection and the high number of medical events, the NRC decided to conduct a special inspection. Facilities that deliver medical treatments involving radiation must make sure that the prescribed treatment is carried out in a safe and precise manner,” said Regional Administrator James Caldwell. “We are concerned with the number of medical events that occurred at the Medical Center in Philadelphia. The special inspection is tasked with helping us understand their causes.” The three-person special inspection team will review the circumstances around the medical events; the methodology used by the Medical Center to examine the events; the procedures used for administering treatment; the Medical Center’s response to the situation; and the corrective actions. The special inspection will also evaluate the training and qualifications of the individuals involved with the iodine-125 prostate cancer treatments and conduct an independent assessment of a sample of the medical events. The duration of a special inspection cannot be determined in advance. The inspection will continue until the inspection goals are achieved. The inspection report will be issued about 45 days after the inspection is complete. It will be available through the NRC RIII Office of Public Affairs and at the NRC web site: http://www.nrc.gov/reading-rm/adams/web-based.html .
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