Safeguards Fail to Protect VA Patients from Surgeon’s Errors
Safeguards Fail to Protect VA Patients
from Surgeon’s Errors
In a page-one story on Sun., June 21, The New York Times reported that significant errors persisted for more than six years at a brachytherapy program at the Veterans’ Medical Center in Philadelphia despite investigation. The Times reports that Dr. Gary D. Kao implanted radioactive seeds incorrectly on repeated occasions as he treated patients with prostate cancer. Twice, he rewrote surgical plans to conceal his error when questioned by federal regulators. There was no program of peer review in the unit, which was staffed through a contract with the University of Pennsylvania School of Medicine. The unit was closed in June 2008 after the Veteran’s Administration national radiation safety unit discovered the pattern of errors in the course of investigating an unrelated mistake. Federal investigators continue to research past problems with the program. The Times reports that the brachytherapy program “botched 92 of 116 cancer treatments over a span of more than six years—and then kept quiet about it…”
To say, as the Nuclear Regulatory Commission found, that the implant program “lacked a safety culture” is a gross understatement. While this story includes an unusual element of apparent misdeed on the part of the surgeon, it is also a large-scale example of James Reason’s “Swiss cheese” model of latent errors.
Into Monday morning, this was the most-emailed article on The New York Times website. Readers’ comments indicate that this important story may add further distraction and confusion to the national debate about healthcare reform, as some readers use this problem at the Philadelphia V.A. to inflame fears some have about a “public option” for health coverage. As the investigation and reporting of this story continue, I hope we take lessons from it in the context of system failure and patient safety, with as little political grandstanding as possible.