NRC fines VA for botched radiation therapy procedures

The Nuclear Regulatory Commission levied on Wednesday its second-largest fine ever for misuse of nuclear medicine, charging the Veterans Affairs Department for an "unprecedented number of medical errors" involving the use of radioisotopes to treat prostate cancer patients during a six-year period.

NRC said the Philadelphia VA Medical Center incorrectly placed iodine-125 seeds in 97 out of 116 patients who were being treated for prostate cancer between 2002 and 2008. NRC, which oversees the use of nuclear medicine, said its fine of $227,500 is one of the largest in its history and highlighted the significance of the mistreatment of veterans at the hospital.

"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," Mark Satorius, regional administrator for NRC's region office in Lisle, Ill., said in a statement.

VA has 30 days to pay the fine or challenge it, NRC said.

In May 2008, NRC was notified of a botched procedure at the hospital, in which a patient received an iodine dose more than 20 percent lower than what was prescribed. It then launched an investigation and found other instances of patients who received incorrect doses of radiation, according to a report the commission completed in November 2009.

VA then suspended radiation therapy at the hospital and barred one clinician from performing prostate cancer treatments at all VA medical facilities, the report noted.

Richard Citron, director of the Philadelphia VA hospital, said in a statement: "There were clearly missed opportunities in oversight from 2002 to 2008.... The fact remains that our VA staff discovered these potential dosing issues almost two years ago, closed the program, self-reported to NRC, cooperated fully with multiple investigations and have been transparent throughout the entire process."

Katie Roberts, the press secretary at VA, said the department takes the Philadelphia situation seriously and has taken steps to correct or mitigate the problem.