No. III-11-002

Contacts: 

Viktoria Mitlyng 630-829-9662

Prema Chandrathil 630-829-9663

 February 23, 2011

 E-Mail: opa3@nrc.gov 

 Web site: www.nrc.gov

NRC ISSUES ORDERS TO TWO INDIVIDUALS INVOLVED IN

2002-2008 MEDICAL ERRORS AT VA MEDICAL CENTER IN PHILADELPHIA

 The Nuclear Regulatory Commission has issued an order that bars a former Veterans 

Administration (VA) physician from engaging in NRC-regulated activities unless he undergoes certain 

training and meets other requirements spelled out by the agency. The order involving Dr. Gary Kao, who 

previously worked at the Veterans Affairs Medical Center in Philadelphia (VA Philadelphia), takes effect 

20 days after its issuance.

 

 At the same time, the NRC has issued a separate order requiring a medical physicist who worked 

at the same facility to notify the agency if he accepts employment in that capacity involving NRCregulated activities. Gregory Desobry must carry out such notification within 20 days of beginning such 

work.

 The orders are the latest actions taken by the NRC in response to an unprecedented number of 

medical errors identified at VA Philadelphia. The errors involved the incorrect placement of iodine-125 

seeds in patients to treat prostate cancer. Out of 116 such brachytherapy procedures performed at the 

facility between 2002 and 2008, the VA reported that 97 were carried out incorrectly. On March 17, the 

NRC issued a $227,500 fine against the Department of Veterans Affairs for violations of agency 

regulations associated with the errors.

 Multiple NRC reviews determined that Kao was the physician involved in 91 of the 97 incorrect 

procedures.

 Previously, two Demands for Information (DFIs) were issued to Kao by the NRC regarding his 

actions, both taken and planned. Despite a commitment by Kao in response to the second DFI to take all 

“necessary and appropriate” steps to ensure his adherence to all applicable requirements during any future 

brachytherapy treatments, the NRC considers the order necessary until Kao takes corrective actions to 

ensure he can safely use radioactive material in accordance with NRC requirements.

 “We are taking this action to protect the public by ensuring that before Dr. Kao works in NRClicensed areas again he proves to the NRC he has addressed his part in the violations at the Philadelphia 

VA Medical Center,” said Roy Zimmerman, Director of the NRC’s Office of Enforcement.

 The order prohibits Kao’s involvement in any NRC-licensed activity, including prostate 

brachytherapy, until, and unless, he does the following: (1) completes specialized training regarding 

medical events and the importance of reporting non-compliances and identifying associated corrective 

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actions; (2) documents successful demonstration of the ability to correctly identify and report medical 

events; and (3) documents his understanding of the definition of a medical event, his roles and 

responsibilities regarding written directives, the steps necessary to identify and report medical events to 

the NRC and the process he would follow to identify corrective actions if he was involved in the future 

with a non-compliance with NRC requirements.

Meanwhile, the NRC’s order to Desobry, who served as the medical physicist for the vast 

majority of the medical events, states that the agency wants the opportunity to inspect his future 

involvement in similar NRC-licensed activities to “verify your understanding of medical events, the role 

and responsibility of the medical physicist regarding medical events, and the steps needed to identify and 

report such events to the NRC.”

The NRC’s response to the VA Philadelphia medical errors included the assignment of a special 

team of inspectors to conduct in-depth inspections of how so many treatments could have been executed 

incorrectly. In addition, the NRC hired an independent medical consultant to assess the impact of medical 

errors on patients. After reviewing data of 39 patients, the consultant concluded 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 concluded 

that a widespread programmatic breakdown had occurred at the facility.

VA Philadelphia subsequently implemented numerous corrective actions, including the 

suspension of the prostate cancer treatment program at the center. The VA Philadelphia brachytherapy 

program remains suspended.

The NRC orders are available in the agency’s ADAMS electronic document system under 

Accession Numbers ML103410384, ML103410390 to Kao and ML103410282 and ML103410284 to 

Desobry.

 

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