For patients with prostate cancer, it is a common surgical procedure: a doctor implants dozens of radioactive seeds to attack the disease. But when Dr. Gary D. Kao treated one patient at the veterans' hospital in Philadelphia, his aim was more than a little off.
Most of the seeds, 40 in all, landed in the patient's healthy bladder, not the prostate.
It was a serious mistake, and under federal rules, regulators investigated. But Dr. Kao, with their consent, made his mistake all but disappear.
He simply rewrote his surgical plan to match the number of seeds in the prostate, investigators said.
The revision may have made Dr. Kao look better, but it did nothing for the patient, who had to undergo a second implant. It failed, too, resulting in an unintended dose to the rectum. Regulators knew nothing of this second mistake because no one reported it.
Two years later, in 2005, Dr. Kao rewrote another surgical plan after putting half the seeds in the wrong organ. Once again, regulators did not object.
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.
One patient was the Rev. Ricardo Flippin, a 21-year veteran of the Air Force. "I couldn't walk and I couldn't stand," he said, citing rectal pain so severe that he had to remain in bed for six months, losing his church job and his income.
Pastor Flippin first learned of what his doctors called a radiation injury not from the V.A., but from an Ohio hospital where he underwent rectal surgery in 2006 to treat the damage. "There are times when I don't have control over my bowels," he said one recent Sunday, after excusing himself during a service at a church in West Virginia where he now preaches.
The 92 implant errors resulted from a systemwide failure in which none of the safeguards that were supposed to protect veterans from poor medical care worked, an examination by The New York Times has found.
Peer review, a staple of every good hospital, in which colleagues examine one another's work, did not exist in the unit. The V.A.'s radiation safety program; the Nuclear Regulatory Commission, which regulates the use of all nuclear materials; and the Joint Commission, a group that accredited the hospital, all failed to intervene; either their inspections had been limited or they had not acted decisively upon finding problems.
More ...
