No. III-10-027 

Contacts: 

Viktoria Mitlyng 630-829-9662 

Prema Chandrathil 630-829-9663 

 June 24, 2010 

 E-Mail: opa3@nrc.gov

Web site: www.nrc.gov

NRC TO HOLD ENFORCEMENT CONFERENCE JUNE 30 

WITH DEPARTMENT OF VETERANS AFFAIRS 

 

The Nuclear Regulatory Commission will hold a predecisional enforcement conference 

June 30 in Lisle, Ill., with the Department of Veterans Affairs (DVA) to discuss apparent violations 

of NRC regulations associated with the performance of DVA medical centers providing prostate 

cancer treatment programs, the National Health Physics Program’s oversight of these hospitals, and 

the DVA’s identification and response to performance issues at these facilities. 

The National Health Physics Program is a department inside DVA responsible for the 

oversight of the DVA’s use of radioactive material, including following up on medical events that 

involve the use of nuclear material including inspections and enforcement actions. 

After the discovery of multiple medical errors at the Veterans Affairs hospital in 

Philadelphia in May 2008, the NRC conducted in-depth inspections to understand the reasons for 

116 medical treatments resulting in 97 medical errors. The NRC identified violations of NRC 

regulations at the DVA hospital in Philadelphia and issued a $227,500 fine. 

As medical errors were being identified at the Philadelphia facility, other DVA hospitals 

with prostate cancer treatment programs began to report similar medical errors. The NRC 

responded by launching additional inspections to determine if the problems identified at the DVA 

facility in Philadelphia existed at the other 13 DVA facilities with prostate cancer treatment 

programs. In addition, the NRC conducted a review of the effectiveness of the National Health 

Physic Program’s response to the events at the Philadelphia facility and other DVA hospitals with 

similar programs. 

Even though the NRC did not identify the same extent of problems at other DVA facilities 

as at the hospital in Philadelphia, they found three apparent violations of NRC regulations at these 

facilities: 1) failure to develop, implement and maintain written procedures to provide high 

confidence that each procedure was carried out in accordance with the physician’s prescription; 2) 

failure to develop, implement, and maintain procedures to verify that each prostate implant adhered 

to the established treatment plan; and 3) failure to notify the NRC about a medical event by the next 

calendar day after its discovery. 

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Office of Public Affairs Region III 

2443 Warrenville Road 

Lisle IL 60532 
In addition, NRC inspectors identified a number of concerns associated with the 

effectiveness of the National Health Physics Program’s response to the problems at the Veterans 

Affairs hospital in Philadelphia and other facilities with prostate cancer treatment programs, such as 

failure to identify violations, the adequacy of enforcement actions, the overall quality of oversight 

of the hospital in Philadelphia, and others. 

The NRC has asked the representatives of the Department of Veterans Affairs to address the 

NRC’s concerns, as well as the apparent violations, during this predecisional enforcement 

conference. 

The meeting, which will be open to public observation, will be at 1 PM (CDT), at the NRC 

Region III Office, 2443 Warrenville Road, in Lisle, Ill. Meeting participants have to go to the 2nd

floor and register with the receptionist. Members of the public who wish to participate by using the 

NRC’s toll-free phone line can contact Viktoria Mitlyng at 630/829-9662 to obtain further details. 

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

decision. No final decisions will be made during this conference. 

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

received during the meeting and the conclusions of the inspections to determine what type of 

action, if any, will be taken against the Department of Veterans Affairs. 

Special inspection reports and other documents associated with the Department of Veterans 

Affairs issue 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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