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Fine against VA Hospital Is Second Largest in NRC History

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Philadelphia, PAOn St. Patrick's Day the Nuclear Regulatory Commission (NRC) hit the Philadelphia VA Medical Center with $227,500 in penalties—one of the largest fines ever levied against a medical institution. While VA hospital malpractice was not alleged, the errors that triggered the large fine could very well be of interest to VA medical malpractice lawyers.

According to a story published on 3/17/10 in the New York Times, federal investigators found that the hospital misplaced radioactive seeds in 97 out of 116 procedures involving patients with prostate cancer between 2002 and 2008.

The report cited the number of radiation errors as "unprecedented."

"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," said Mark Satorius, a regional administrator for the commission.

The NRC regulates the use of nuclear isotopes in medical treatment. The commission rarely issues fines exceeding several thousands of dollars over errors involving nuclear radiation. The largest fine ever ever levied was 15 years ago and totaled $280,000.

Richard Citron, director of the Philadelphia Veterans Affairs Medical Center, defended the facility: "The fact remains that our VA staff self-discovered these potential dosing issues almost two years ago, closed the program, self-reported to the NRC, cooperated fully with multiple investigations and have been transparent throughout the entire process."

He did acknowledge that there had been shortcomings in its oversight at the time that the errors occurred.

The penalty is not borne by the hospital but rather by the Department of Veterans Affairs, which is reportedly challenging the commission's findings. A spokesperson for the nuclear commission indicated that while the agency initially concurred with the commission's findings, the VA has since altered its position and disputes the number of errors made at the Philadelphia facility, together with the NRC's own definition of a medical error.

The full scope of problems at the Philadelphia VA hospital came to light in June 2009. The New York Times found that Dr. Gary D. Kao, a radiation oncologist, had been responsible for the vast majority of the errors.

Dr. Kao no longer practices at the hospital.

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