Sunday, June 21, 2009

Systemic Error at Philadelphia VA

Today, the New York Times provides a detailed article on a disturbing case of medical error and failure of oversight at the Philadelphia VA Hospital where a practitioner failed to correctly perform 92 of 116 prostate procedures, leaving patients with radioactive seeds in tissue outside of their prostate. The mistakes were ignored and covered up until an administrative error drew the attention of the VA's national radiation safety unit.

The article correctly focuses on the lack of administrative oversight and "safety culture" that allowed these problems to continue. The article is also accompanied by a great video that highlights the personal impact on one patient.

It's a rogue's gallery of systemic problems, including:
- continued practitioner error and substandard equipment
- contractors from a well-regarded academic institution do not receive the normal level of oversight
- continuing errors are tolerated or undetected by supervisors and institutional oversight boards, and there is lack of peer review (swiss cheese at its best)
- lack of external authority to question alteration of medical records
- practitioner seen by the patient is not the practitioner performing the procedure
- patient undergoes more suffering due to subsequent misdiagnosing of the medical error by other practitioners.
- the error is finally acknowledged by the institution, but no apology or support is provided.

The unit was shut down in June 2008, and results of an investigation were recently released. Interestingly, this article is currently the #3 most forwarded article on the New York Times site.

Update: New York Times is hosting a discussion of radiation treatments. Many stories of negative experiences, but also discussion of the value of radiation treatment and treatment with few negative effects.


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