No. III-09-033 

Contacts: 

Viktoria Mitlyng 630-829-9662 

Prema Chandrathil 630-829-9663 

 November 18, 2009 

 E-Mail: opa3@nrc.gov 

Web site: www.nrc.gov

NRC COMPLETES INSPECTION OF MEDICAL ERRORS 

AT VETERANS AFFAIRS HOSPITAL IN PHILADELPHIA 

A special inspection of multiple medical errors during prostate cancer treatments at the 

Philadelphia Veterans Affairs Medical Center (VA Philadelphia) has revealed eight apparent 

violations of Nuclear Regulatory Commission (NRC) regulations, the agency said on 

Wednesday. The agency will meet with VA officials Dec. 17 to discuss the issue before making 

any enforcement decisions. 

Medical errors at VA Philadelphia involved the incorrect placement of iodine-125 seeds 

used to treat prostate cancer. The medical center’s review of prostate cancer treatments had 

identified 98 medical errors out of the total of 116 treatments conducted on 114 veterans between 

2002 and 2008. 

“The health and safety of US veterans are of paramount importance to the agency,” said 

Mark Satorius, regional administrator for NRC Region III Office, in Lisle, Ill. “The NRC 

mounted a comprehensive special inspection to determine what went wrong at VA Philadelphia. 

We discovered an absence of safety checks and balances. They must be in place to ensure safe 

and quality care for patients.” 

“The NRC expects licensees who use nuclear materials in medicine to do so responsibly. 

We hope learning from this experience will prevent such egregious errors in the future,” Satorius 

added. 

In its first phase, from July 2008 to February 2009, the NRC investigation reviewed the 

circumstances around the medical events, focusing on identifying programmatic weaknesses. 

The second part of the inspection, from June 2009 – October 2009, focused on verifying 

the accuracy of radiation dose calculations provided to the NRC by VA Philadelphia. 

The NRC inspection team reviewed final dose calculations for all 114 veterans treated at 

the facility (two patients received two treatments). Verifying radiation doses enabled the NRC to 

evaluate if the radiation dose prescribed matched the dose received. The accuracy of these 

records is vital for medical experts to assess the seriousness of injuries to patients, including the 

potential for continuing medical issues, increased risk of recurrence of cancer and the need for 

continuing patient follow up. 

NRC NEWS

U.S. NUCLEAR REGULATORY COMMISSION

Office of Public Affairs Region III 

2443 Warrenville Road 

Lisle IL 60532 
This issue first came to the NRC’s attention in May 2008, followed by the discovery of 

more medical events at VA Philadelphia that involved delivery of a dose that was either 20 

percent higher or lower than the prescribed dose or delivery to an unintended area. 

The NRC hired a medical consultant to determine possible adverse health consequences 

to the patient that could be caused by medical errors. The consultant reviewed the dose records 

and other data of 39 patients; he stated that several patients experienced symptoms that could be 

related to the medical errors in their treatment, such as inflammation and damage to the lower 

parts of the colon, rectal bleeding and recurrence of cancer. 

The NRC identified eight apparent violations. They are associated with the lack of 

procedures that would help ensure that each prostate cancer treatment adheres to the prescription 

written by the physician; absence of verification tools to ensure that the treatment was delivered 

as prescribed; failure to instruct personnel in identification and reporting requirements for 

medical events; failure to record the dose received by a patient on the doctors’ prescription form; 

failure to make sure all written reports are complete and accurate; and failure to notify the NRC 

no later than the next calendar day after discovery of a medical event. 

A predecisional enforcement conference between the NRC and the Department of 

Veterans Affairs (DVA) will be held on December 17, 2009, at 1 PM (EST), in the 

Commissioners’ Conference Room, One White Flint North, 11555 Rockville Pike, Rockville, 

Md. This conference is being held to obtain information to assist the NRC in making an 

enforcement decision. 

After the predecisional enforcement conference, the NRC will review the information 

received during the conference and the conclusions of the special inspection to determine what 

type of action will be taken against the Department of Veterans Affairs. 

The reports documenting the findings of both parts of the special inspection and the 

reports of the medical consultant will be available through the NRC RIII Office of Public Affairs 

and at the NRC web site: http://www.nrc.gov/reading-rm/adams/web-based.html. The NRC will 

continue inspection efforts with the focus on other Veterans Affairs prostate cancer treatment 

programs and the National Health Physics Program. 

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