For patients with prostate cancer, it is a common surgical procedure: a doctor implants dozens of radioactive seeds to attack the disease. But when Dr. Gary D. Kao treated one patient at the veterans’ hospital in Philadelphia, his aim was more than a little off.
Most of the seeds, 40 in all, landed in the patient’s healthy bladder, not the prostate.
It was a serious mistake, and under federal rules, regulators investigated. But Dr. Kao, with their consent, made his mistake all but disappear.
He simply rewrote his surgical plan to match the number of seeds in the prostate, investigators said.
The revision may have made Dr. Kao look better, but it did nothing for the patient, who had to undergo a second implant. It failed, too, resulting in an unintended dose to the rectum. Regulators knew nothing of this second mistake because no one reported it.
The concern is that if this type of treatment is happening to other veterans due to budget issues, how much more dangerous would it become if the VA Modality is used for Health Care Reform? Not too long ago in several VA Medical Centers, endoscopy equipment was not properly sterilized and thousand of Veterans were exposed to HIV, Hepatitis, and other diseases.
Failed Prostate Procedures at the Philadelphia V.A. Document Reader: Inside a Patient’s Medical Records