VA blames "offline computer" for radiation errors, but there seem to be larger problems

by: Jason Springer

Mon Jul 20, 2009 at 04:00:00 PM EDT

This story isn't going away. Congressman Adler has been trying to get answers to what happened that caused apparent medical misconduct at the VA hospital in Philadelphia resulting in mistakes regarding cancer procedures and treatments. We're now starting to hear about the veterans who received the mistaken treatment and how the VA is trying to explain it away:

Armstrong's doctors, led by University of Pennsylvania radiation oncologist Gary Kao, didn't recognize their error because they hadn't done the crucial last step of the brachytherapy procedure - calculating the actual radiation dosage administered to their patient - investigators found.
For a year, starting in November 2006, the computer workstation with the software used to calculate the post-implant dosages was unplugged from the hospital's network.
All that time, no one took steps to plug it back in, work around it, or tell patient-safety officials, investigators found.
As a result, post-implant calculations weren't performed during that period for Armstrong and 15 other patients, according to the U.S. Nuclear Regulatory Commission, which oversees medical use of radiation.
Even after the computer was finally reconnected to the network, investigators discovered, post-implant calculations continued to be omitted for an additional seven patients.

So the VA would like people to just accept their explanation that it's the computer's fault because it wasn't plugged in, but then when they plugged in the computer, the work still wasn't done to do the post calculations? It sounds more like the fault of the people who were supposed to be using the computer. Congressman Adler isn't satisfied with the explanations he has been receiving:

"The VA abdicated its responsibility . . . by allowing this program to operate without adequate safeguards or supervision," said U.S. Rep. John Adler (D., N.J.), who has pushed for a congressional investigation.

He'll will try to get some more answers this week when another congressional panel holds a hearing in Washington to question representatives and doctors from the VA, Penn and the NRC. Follow me below the fold for more of the story.

Jason Springer :: VA blames "offline computer" for radiation errors, but there seem to be larger problems

It seems that although federal law doesn't require the check after the procedure, it is considered good practice:

Tamara A. LaCouture, acting chief of radiation oncology at Cooper University Hospital in Camden, said an implant there would be canceled or postponed rather than go without post-implant dosimetry.
It is not surprising, then, that NRC and VA investigators spent considerable time delving into why the calculations weren't done for more than a year at the Philadelphia VA.
Their investigative reports blamed a "computer interface problem" - the same terminology Kao used during his testimony last month at a congressional hearing.
The implication was that some intractable technology breakdown was behind the lapse in care.
In fact, technology had little to do with the breakdown, as James Bagian discovered when he led an inquiry at the Philadelphia VA and the veterans' health system's 12 other brachytherapy programs.

So the VA says it was technology, but others in the medical industry dispute that contention and say it had little to do with the problems. And while Dr. Kao has been the only public official in the spotlight, he wasn't alone apparently:

Kao, who did almost all the errant procedures, is the only person officials have publicly identified. But many others - including medical physicists, urologists, and radiation technologists from Penn, and VA employees - played key roles in the program.
Penn, which trains young doctors at the hospital, contracts with the VA to provide a raft of medical services, including radiation oncology.

Lives have been changed by these mistakes:

For Armstrong, the aftershocks of his original care at the Philadelphia VA added to the fallout of fighting in Vietnam - namely, posttraumatic stress syndrome.
"My girlfriend left me because of [erectile dysfunction]," he said during an interview in his lawyer Michael Barrett's Center City office. "I am just learning to be alone."
He also lives in fear the cancer will return, and of the tiny nuclear war inside him.
"I feel things in my body and think the worst," he wrote on the claim form he filed with the VA last summer. "I really don't know when something is going to happen. I can't get past it. I get depressed a lot."

It appears there were problems on so many levels and unfortunately while people try to cover their own rear end, veterans who thought they were receiving the care they needed are now experiencing problems they never should have had.