The Nuclear Regulatory Commission issued a 51-page report early this week based on inspections of the 12 Veterans Affairs hospitals that currently have brachytherapy programs. Brachytherapy is a prostate cancer treatments in which radioactive seeds are implanted near cancerous tissue.
The inspections and subsequent report came after former School of Medicine Radiology Professor Gary Kao reportedly misplaced seeds in 97 of 116 procedures at the Philadelphia Veteran Affairs Medical Center.
NRC representative Viktoria Mitlyng said the errors at the Philadelphia VA Hospital were “so severe” that the NRC wanted to ensure “other Veterans Affairs facilities throughout the country didn’t have the same problems.”
In January, the U.S. Department of Veterans Affairs took responsibility for the botched procedures and in March the NRC — a government agency that regulates that use of nuclear materials — issued the Philadelphia VA hospital a $227,500 fine. This is the second-largest fine the NRC has required for medical mistakes.
The inspections sought to determine whether the VA was correctly performing the functions required by their Master Materials License both in Philadelphia and across the nation, Mitlyng explained.
This special license gives certain government agencies oversight in their own use of nuclear materials. The license is only issued to government agencies that handle nuclear material at multiple locations such as the U.S. Navy, she said.
Under the license, the VA is expected to perform functions typically carried out by the NRC. These include inspecting VA facilities before and after procedures and determining how to enforce regulations.
The NRC found that despite performing the required inspections, the VA “failed to identify specific violations,” according to Mitlyng,
“We have concerns with the overall quality of the Veterans Affairs Master Material License Program. We have concerns with how the program is being implemented,” she said.
The VA is expected to respond to the NRC’s questions and concerns as detailed in the report at a predecisional enforcement conference on June 30.
Since the hospital’s brachytherapy program has been suspended, the Philadelphia VA hospital will not be present at the conference. According to Mitlyng, “they don’t have any plans to restart the program.”
For the 12 VA hospitals maintaining the program, the most drastic potential change is that “oversight of the separate VA hospitals would go back to the NRC.”
The VA hospitals could either voluntarily go back to the NRC or the NRC could revoke the Master Materials license, Mitlyng explained.
