No. III-10-005 

Contacts: 

Viktoria Mitlyng 630-829-9662 

Prema Chandrathil 630-829-9663 

 March 17, 2010 

 E-Mail: opa3@nrc.gov

Web site: www.nrc.gov

NRC PROPOSES $227,500 FINE AGAINST 

DEPARTMENT OF VETERANS AFFAIRS 

The Nuclear Regulatory Commission has proposed a $227,500 fine against the 

Department of Veterans Affairs (DVA) for violations of NRC regulations associated with an 

unprecedented number of medical errors identified at the Veterans Affairs Medical Center in 

Philadelphia (VA Philadelphia). 

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

to treat prostate cancer. Out of 116 procedures performed between 2002 and 2008, 97 were 

executed incorrectly. 

“This substantial fine emphasizes the high significance of violations at the Philadelphia 

Veterans Affairs Medical Center that resulted in close to 100 of our nation’s veterans receiving 

substandard treatments,” said Mark Satorius, regional administrator for the NRC’s Region III 

office in Lisle, Ill. “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.” 

This is one of the largest fines ever proposed by the NRC for medical errors. The 

principal violations, assessed at $208,000, are associated with the lack of written procedures to 

provide high confidence that each treatment was implemented as prescribed and the lack of a 

procedure to verify that the treatment was implemented correctly. Additional violations, assessed 

at $19,500, involve the wrong dose of radioactive seeds being ordered and implanted into a 

patient on May 5, 2008, because no procedure existed to verify correct implementation of 

treatment; the lack of training in the NRC’s definition of a medical event and associated 

reportability requirements; and the failure to report medical events to the NRC no later than the 

next calendar day. 

The NRC responded aggressively and decisively when medical errors at the VA hospital 

in Philadelphia came to light in May 2008. The NRC dedicated a special team of inspectors to 

conduct extensive in-depth inspections to determine how 97 of 116 treatments could have been 

NRC NEWS

U.S. NUCLEAR REGULATORY COMMISSION

Office of Public Affairs Region III 

2443 Warrenville Road 

Lisle IL 60532 
executed incorrectly. In addition, the NRC hired an independent medical consultant to assess the 

impact of medical errors on patients. NRC inspectors determined a widespread programmatic 

breakdown had occurred within the cancer treatment program at VA Philadelphia. Inspection 

findings are documented in two inspection reports which can be accessed at the NRC web site: 

http://www.nrc.gov/reading-rm/adams.html. Use ML090900382 and ML093210599 as search 

terms. 

The DVA took a number of corrective actions to address problems identified by the NRC 

at VA Philadelphia. They included suspending the VA Philadelphia prostate cancer treatment 

program; ordering external reviews; revising procedures; providing radiation safety training to 

oncology staff; instituting an internal quality assurance program; removing one individual from 

performing prostate cancer treatments at DVA facilities; and others. The VA Philadelphia 

prostate cancer treatment program will remain suspended and cannot be restarted without 

informing the NRC. 

The NRC expanded its inspection efforts to other DVA facilities with prostate cancer 

treatment programs and the National Health Physics Program (NHPP), the DVA’s regulatory arm 

responsible for the oversight of medical facilities. For the NRC to have confidence that other 

DVA facilities did not suffer from the severity of the problems found at VA Philadelphia, an 

expanded review of other DVA facilities was necessary. Even though NRC inspectors identified 

some concerns, they did not reach the level of the widespread programmatic breakdown that 

afflicted VA Philadelphia. In addition, the agency found it imperative to make an assessment 

regarding the NHPP’s effectiveness as a regulator. The results of this inspection will be 

documented in a report to be issued later this year. If violations to NRC regulations are identified, 

the NRC will take appropriate enforcement actions. 

The DVA has 30 days to either pay the proposed fine or challenge it. 

The NRC’s letter, its enclosures, and the DVA’s response will be available to the public 

through the agency’s public electronic reading room at: http://www.nrc.gov/readingrm/adams.html. Help in accessing these documents is available from the NRC Public Document 

Room at 1-800-397-4209. 

 ### 

 NRC news releases are available through a free list serve subscription at the following Web 

address: http://www.nrc.gov/public-involve/listserver.html. The NRC homepage at www.nrc.gov also 

offers a SUBSCRIBE link. E-mail notifications are sent to subscribers when news releases are posted to NRC's 

Web site.