No. III-08-033 

Contacts: Viktoria Mitlyng 630-829-9662 

 Prema Chandrathil 630-829-9663 

 September 9, 2008 

 E-Mail: opa3@nrc.gov 

Web site: www.nrc.gov

NRC BEGINS SPECIAL INSPECTION OF THE DEPARTMENT OF VETERANS 

AFFAIRS DUE TO MULTIPLE MEDICAL EVENTS 

The Nuclear Regulatory Commission is conducting a special inspection at the Veterans 

Affairs Medical Center in Philadelphia, PA, to examine the circumstances surrounding multiple 

underdoses during radiation treatments of prostate cancer that occurred between February 2002 

and June 2008. 

On May 18, 2008, the Department of Veterans Affairs National Health Physics Program 

notified the Nuclear Regulatory Commission that the radiation dose delivered to a patient at the 

Veterans Affairs Medical Center in Philadelphia, PA, to treat prostate cancer was more than 20 

percent lower than the prescribed dose. The treatment involved implanting iodine-125 seeds of a 

prescribed radiation dose into the patient’s prostate. During the event on May 5, iodine-125 seeds 

used in the procedure were of incorrect radiation dose. 

The National Health Physics Program conducted an inspection in May and June of this 

year in response to the May 5 event. In all, 112 procedures that took place since the inception of 

the cancer treatment program in Feb. 2002 were reviewed. Fifty-five of these cases were 

identified as medical events that involved administering an incorrect radiation dose to a patient. 

As a result of the review, the VA Medical Center suspended its prostate cancer treatment 

program in June 2008. 

The Medical Center is reviewing possible effects on patients. Circumstances for each 

patient are being evaluated to determine if follow-up medical care is needed. 

NRC Region III conducted a reactive inspection at the Medical Center in July of this year. 

Based on the results of this inspection and the high number of medical events, the NRC decided 

to conduct a special inspection. 

“Facilities that deliver medical treatments involving radiation must make sure that the 

prescribed treatment is carried out in a safe and precise manner,” said Regional Administrator 

NRC NEWS

U.S. NUCLEAR REGULATORY COMMISSION

Office of Public Affairs Region III 

2443 Warrenville Road 

Lisle IL 60532 
James Caldwell. “We are concerned with the number of medical events that occurred at the 

Medical Center in Philadelphia. The special inspection is tasked with helping us understand their 

causes.” 

The three-person special inspection team will review the circumstances around the 

medical events; the methodology used by the Medical Center to examine the events; the 

procedures used for administering treatment; the Medical Center’s response to the situation; and 

the corrective actions. The special inspection will also evaluate the training and qualifications of 

the individuals involved with the iodine-125 prostate cancer treatments and conduct an 

independent assessment of a sample of the medical events. 

The duration of a special inspection cannot be determined in advance. The inspection will 

continue until the inspection goals are achieved. The inspection report will be issued about 45 

days after the inspection is complete. It 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 . 

 

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