A six year series of the same medical error

June 22, 2009

surgeryI was made aware of a series of medical errors in brachytherapy by the Health Care Renewal blog. The original article is here. Brachytherapy is a treatment for prostate cancer where small radioactive seeds are implanted in the prostate.

As a quick summary, at the VA hospital in Philadelphia, over a six year period, 92 out of 116 brachytherapy treatments were performed incorrectly, often leading to serious complications. The VA had contracted out the treatments with one of the contractors being from the University of Pennsylvania and board certified in radiation oncology.

In the article:

Two days later, the Joint Commission, which helps set standards in the hospital industry, surveyed the Philadelphia V.A. and on the next day accredited the hospital. “This organization is in full compliance with applicable standards,” the Joint Commission said.

The commission said that it had no indications of the problems in the brachytherapy program when it arrived at the hospital and that its surveys are not detailed enough to have uncovered the flawed implants.

I have previously written about the fact that medical errors happen at accredited hospitals. But for the same error to recur for six years says the accreditation system is flawed.

I was also struck by:

Susan Phillips, a senior executive at Penn’s medical school and health system, said Dr. Kao had voluntarily given up his clinical privileges there, though he continues to do research on campus.

Since it was shown that Dr. Kao falsified records during several brachytherapy procedures, why is he still doing research. Dr. Kao is listed as part of the clinical faculty of the University of Pennsylvania department of radiation oncology. The University of Pennsylvania is building a proton beam therapy (PBT) facility (scheduled to open in 2009) and will be the sixth such center to offer PBT treatment in the US.