Personal Injury Law

Medical Errors At VA Hospital Concealed

Our Atlanta medical malpractice attorneys frequently see cases in which the practices engaged in by physicians are questionable. Yet in many instances the practices are so egregious that one has to wonder how the medical establishment could allow them to occur or continue. Yesterday, the New York Times reported just such a situation at a VA Hospital in Philadelphia.

In a common treatment for prostate cancer, doctors implant dozens of radioactive seeds in the prostate to attack the cancerous cells. But, according to reports, when Dr. Gary D. Kao treated one patient at the VA hospital in Philadelphia, his aim was more than a little off.

Most of the seeds, 40 in all, were implanted in the patient?s healthy bladder, not the prostate.
It was an egregious error, but according to the report, with the help of federal regulators Dr. Kao, was able to conceal his mistake. He was allowed to rewrite his operative note to match the number of seeds in the prostate.

The patient had to undergo a second implant which also failed, resulting in an unintended dose to the rectum. Regulators knew nothing of this second mistake because no one reported it.
The report disclosed that two years later, in 2005, Dr. Kao again changed an operative note after putting half the seeds in the wrong organ. Once again, regulators did not object.

This was only the tip of the iceberg. The Cancer unit at the VA Philadelphia hospital operated with virtually no outside scrutiny and botched 92 of 116 cancer treatments over a span of more than six years , and then concealed the errors.

The physicians in the unit continued implants for a year even though the equipment that measured whether patients received the proper radiation dose was broken. The radiation safety committee at the Veterans Affairs hospital knew of this problem but took no action.

The Times concluded that the 92 implant errors resulted from a systemwide failure in which none of the safeguards that were supposed to protect veterans from poor medical care worked. Peer review, in which physicians examine one another?s work, did not exist in the unit. The V.A.?s radiation safety program; the Nuclear Regulatory Commission, which regulates the use of all nuclear materials; and the Joint Commission, a group that accredited the hospital, all failed to intervene.

Virtually none of the substandard implants in Philadelphia were reported to the nuclear commission, meaning errors went uninvestigated for weeks, months and sometimes years. During that time, many patients did not know that their cancer treatments were flawed.

Many of the patients, all veterans, suffered severe pain and other problems, such as incontinence, as a result of these errors.

This report comes on the heels of another disclosure some months ago that VA Hospitals were failing to properly sterilize medical equipment, exposing veterans to the risk of infectious diseases such as hepatitis and AIDS. Surely, our veterans deserve better.

Full post as published by Georgia Injury Lawyer Blog on June 22, 2009 (boomark / email).