Philadelphia VA Hospital radiation errors blamed on offline computer
July 30, 2009 posted by Robert L. Hanafin · 9 Comments
The medical blog Health Care Renewal with doctors being the primary writers, had this article submitted that noted the Philadelphia VA Hospital Cancer Radiation Therapy Debacle: For The Want of One Competent and Industrious IT Person.
It was posted by a Medical Informatics MD who wrote that this story should perhaps be subtitled "The Theatre of the Absurd."
An extract of comments made in that article follows in the comments section after this update from the Philadelphia Inquirer.
Robert L. Hanafin
Veterans Advocacy Editor
Major, U.S. Air Force-Retired
Veterans Today News Network &
Our Troops News Ladder
Vietnam Veteran James Armstrong had no way to know that his prostate-cancer treatment had gone dangerously awry as he recovered from the brief procedure at the Philadelphia VA Medical Center in August 2007. Doctors for the war veteran from West Philadelphia, however, should have known, federal investigators concluded. The dozens of tiny radioactive seeds they had implanted in Armstrong’s prostate gland were delivering only about a quarter of the radiation called for in his treatment plan – too little by established standards to wipe out his cancer. 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.
The unplugged computer was symbolic of the management disconnection and disregard that investigators say pervaded the brachytherapy program at the Philadelphia VA. Between February 2002, when the program opened, and June 2008, when it was shut down, 92 of 114 prostate-cancer patients received too little radiation or too much.
A congressional panel held hearings in Washington to question Kao and other key individuals from the VA, Penn and the NRC because, "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.
Viewed as essential
There are no laws or federal regulations requiring that radiation doses be calculated after a radiation isotope implant. However, professional radiology organizations say it is essential for good practice.
[NOTE for readers ‘like me' with a high school GED, Brachytherapy does not use drugs per se in the treatment of certain cancers but are implanted solid gold Au-198 and iridium Ir-192 seed implants of well radiation. Simply put it is nuclear medicine or radiation therapy. VT, ed.]
The Acting Chief of radiation oncology at Cooper University Hospital in Camden, New Jersey said an implant at their hospital would have been canceled or postponed rather than go without post-implant analysis. It is not surprising, then, that NRC and VA investigators spent considerable [buying] 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 Dr. 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. WRONG!
In fact, technology had little to do with the breakdown, as James Bagian a Philadelphia-born physician and former astronaut who is now the VA’s national patient-safety director, discovered when he led a recent inquiry at the Philadelphia VA and the veterans’ health system’s 12 other brachytherapy programs. His investigation discovered that the "interface problem" was nothing more than the disconnected computer.
Here’s what else his inquiry found:
The computer was initially unplugged so that another medical device could use the network port. Then, various departments dithered and ducked a request for an additional network port, which was finally installed – after a year. Some doctors, physicists, and other professionals at the VA acknowledged it was "clinically inappropriate" to omit the post-implant calculations. Some said they had informed their "chain of command."
[Pay special attention to how some doctors, physicists, and other professional at the VA informed their "chain of command," that what they were doing was "clinically inappropriate". The smart questions anyone should have asked these medical professional is exactly who in their chain of command are they talking about administrative management, medical management or both? They sure as hell did not inform the hospital's patient-safety officer. VT, Ed.]
When asked why they didn’t tell the hospital’s patient-safety officer, they said "it had not occurred to them to do so."
VA National Press Secretary Katie Roberts said that the department had shut down the Philadelphia program after the problem was discovered last spring and since that time had worked to inform and treat all the affected veterans.
"VA deeply regrets this unfortunate occurrence," Roberts said in a statement. "VA is actively using this experience to implement stricter protocols of accountability and transparency throughout the department."
[Note: Katie Roberts is the VA's top talking dog, when the VA gets into trouble she barks. Seriously, she is a political appointee from the spoils system, the former Communications Director for Governor Bill Richardson's unsuccessful run on the White House. Very interesting, but so much for credibility representing what's best for America's Veterans that is unless Ms. Roberts is a Veteran that I highly doubt. The VA just doesn't hire Veterans for such influential posts. This is but another case where change of political regimes at VA upper and middle management really doesn't change a damn thing. VT, Ed.]
TOO Many played key roles
Reviews by the VA and the NRC found that the brachytherapy program under dosed 57 veterans while 37 got excessive doses of radiation to nearby tissues. Dr. 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, No one can say how many of the 92 veterans face a poor prognosis as a result of the treatment lapses, but for Armstrong, the damage is clear.
[The University of Pennsylvania trains young doctors at the hospital, contracts with the VA to provide a raft of medical services, including radiation oncology.]
Vietnam Veteran James Armstrong
Like the other men who received inferior VA care, James Armstrong learned of it last summer. Philadelphia VA officials asked the 62-year-old veteran to come in for a new CAT scan that would be used to review the quality of his implant. The VA’s review showed that his prostate had received only 27 percent of the prescribed radiation dose. And it appeared that his bladder and bowel received excessive radiation from errantly placed seeds. Armstrong now suffers from severe pain during urination. He also has trouble controlling his bladder and bowels.
Last October 2008, the VA flew Armstrong – and seven other veterans with suspected treatment failures – to the Puget Sound VA in Seattle, an internationally recognized leader in brachytherapy (radiation therapy). There, the men received corrective "touch-up" implants. Armstrong’s "original implant was grossly inadequate by current standards," radiation oncologist Kent Wallner, the VA expert who re-treated Armstrong, wrote in an Oct. 20, 2008, letter.
"The resulting complicated situation leaves him at considerable uncertainty regarding his chance for a cure," Wallner wrote. "He is also . . . at higher than usual risk for severe urinary or bowel complications due primarily to excess radiation."
Like Dr. Kao, Dr. Wallner inserted needles loaded with radioactive seeds [isotopes] into Armstrong’s prostate while watching ultrasound images of the organ. But Wallner was so exacting that after placing 40 seeds in Armstrong’s prostate; the doctor gauged the radiation dosage, and then added four more rice-grain-sized particles.
"We elected to add four more seeds to try to bring it up closer to 100" percent, Wallner wrote in his operative note.
For Armstrong, the aftershocks of his original care at the Philadelphia VA added to the fallout of fighting in Vietnam – namely, post traumatic stress syndrome [PTSD]. 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."
Of course James Armstrong will be filing a malpractice suit againt the VA.
As mentioned in a previous Veterans Today article on this, VA scandals are long-term systemic problems not a few bad apples ,
During the recent Senate Veterans Affairs Committee hearing, several senators wondered how the Joint Commission could have given the Philly VAMC its accreditation given that circumstance. In response Robert Wise, vice president of standards and survey methods for the Joint Commission said, "We need to pull back and take a look at this."
We believe that pulling back and taking a look at this, whatever Robert Wise really meant to say IS NOT THE RIGHT ANSWER? It certainly did not respond to Senator’s questions regarding why the Joint Commission gave the Philadelphia VAMC its accreditation?
Below is a little background on the Joint Commission and we encourage anyone, patient, doctor, nurse, clerical employee working for the VA to contact the Joint Commission, and bombard them with both complaints and praise of the patient safety and care within our VA Hospitals, because there’s something very wrong at the Joint Commission when one of its Vice Presidents (a non-profit at that) tells members of Congress that when a VA Hospital harms or mistreats America’s Veterans, "We need to pull back and take a look at this." At least Mr. Wist should have explained what he really meant by that.
Addressing threats to health care’s core values, especially those stemming from concentration and abuse of power.
A doctor writing for Healthcare Renewal [www.hcrenewal.blogspot.com] noted that remarkable accommodation is often given to IT personnel in hospitals, even when these personnel make decisions that are contrary to the support of the mission of healthcare organizations. Many health IT problems appeared due to ill-informed, edicts of over empowered Medical Information System leaders, (relative to clinical leadership) sanctioned by equally ill-informed executive administrative leadership, for which the IT personnel were rarely held accountable.
Endangerment of ICU patients [www.ischool.drexel.edu] via PC’s is entirely inappropriate for a biohazards environment, chaos in a critical procedure area [www.ischool.drexel.edu] from IT complacency and incompetence, payment of millions of dollars for Health IT with gross defects rendering it unusable [www.ischool.drexel.edu] by clinicians without consultation of in-house medical informatics expertise, and denial of access for hundreds of drug discovery scientists [www.ischool.drexel.edu] to the informatics tools their own leaders said were essential to new drug discovery are just a few of the situations observed due to IT department whimsy.
Remarkably, none of these situations nor others reported from numerous sources resulted in repercussions against the IT deities (other than, in some cases, generous promotions), thereby obstructing reform of the attitudinal and competency problems that created the scenarios. If physicians had it this good, they’d be chopping off wrong limbs, removing the wrong organs, and failing to diagnose and treat with impunity.
Back in June 2009 a clinical debacle of national import unfolding at the Philadelphia VA hospital entitled " Bungled Brachytherapy, Computer Interfaces and Other Mysteries At The Philadelphia Veterans Administration Hospital [hcrenewal.blogspot.com]":
A question was raised about being uncertain how "computer interface problems" (in the Philadelphia Inquirer [www.philly.com], they were referred to as "glitches") prevented medical personnel from determining treatment success over several years. I would be most interested in hearing more about these "interface problems." That question has now been answered, and the thought that perhaps some arcane coding or driver configuration was the culprit at the VAMC Philadelphia. That was not the case.
Their investigative reports blamed a "computer interface problem" – the same terminology Dr. 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 [i.e., some cryptic problem requiring magical incantations and byzantine scripts that mere mortals could not understand nor remedy.]
The computer was initially unplugged so that another medical device could use the network port. Then, various departments dithered and ducked a request for an additional network port, which was finally installed – after a year.
"Various departments dithered and ducked?" Which departments, exactly?
[Here we have medical professionals raising the same questions we at Veterans Today did. VT, ed.]
When asked why they didn’t tell the hospital’s patient-safety officer, they said "it had not occurred to them to do so."
["Had not occurred to them to do so?" I've seen situations where physicians and scientists were afraid of IT leaders, due to the latter's often overinflated political influence and proficiency in playing games of political intrigue. Did this occur here, I wonder?]
So, it appears that for the want of one network connection, installed by one competent, industrious, non-complacent IT person, a national scandal has erupted that has injured many Veterans.
I note again that multiple people failed here, including executives, physicians, safety officers, etc. I believe responsibility needs to be fairly assigned. However, IT needs to be included. I’ve witnessed or heard about too many Health IT incidents where IT personnel and leadership remained scot-free when their behavior and attitudes were contributors or root causes.
As per my letter to the editor published in JAMA on July 22, " Health Care Information Technology, Hospital Responsibilities, and Joint Commission Standards [jama.ama-assn.org]", IT privilege and accommodation must stop. Heathcare IT is not business IT used for widget inventory or payroll. As the VA incident shows, patient lives and well being are at stake.
More on this from a blog on medical physics, "The Sharp End of the Photon", here [www.drflounder.com]:
… the errors in the placement of the radioactive seeds went undiscovered for so long because post-implant dosimetry was not performed. This involves CT scanning the patient, finding the positions of the seeds and calculating the ultimate dose the patient received. In the NRC report, the explanation was that a problem with the interface between the CT scanner and the treatment planning computer prevented transferring the CT images.
First, the following questions regarding the "various departments" that "dithered and ducked" the responsibility to install an additional network connection in the brachytherapy suite:
Was the job the responsibility of the Department of Medicine? The doctors and nurses? Could they have done so?
(If you need help answering these questions, stop reading now.)
I can visualize what went on behind the scenes in the IT department, refrains I have heard before – "we don’t have the resources … we need to hold more meetings to consider the issues … it’s the vendor’s responsibility … it’s the network group’s job, not the hardware group … putting a new network outlet in there will cause packet storms and interfere with system XYZ … we need to get consensus …. you [doctors] can’t understand the complexities of the problem, but don’t worry, we’ll make it better … hey, the docs don’t need it anyway …"
What would happen to, say, the Facilities Department if a plumbing problem led to failure of a piece of vital equipment in the OR’s, and they failed to repair it for a year?
This is not to excuse the multiple layers of complacency among clinicians, safety staff, and others for toleration of this network denial situation and the lack of QC on the procedures themselves, but at the heart of this debacle is this attitude, which seems common in hospital IT departments:
"Doctors and nurses toil in hospitals so IT personnel can have comfy jobs and nifty computers."
Perhaps on this occasion, IT leaders and personnel may end up on the witness stand and be held accountable, and perhaps lose their jobs instead of being promoted.
However, even this is doubtful, and it has taken a congressional investigation led by Sen. Arlen Specter to get even this far, to simply find out that the mysterious "interface glitches" were a lack of a network jack due to laziness and complacency.
Finally, I point out that it is hospital IT personnel upon whom clinicians will depend for acquisition and implementation of the Health IT tools the President of the United States said are essential to changing the culture of healthcare. As I have written, before the IT profession can change the culture of healthcare (in a positive manner, that is), its own culture must change. IT personnel in hospitals must become part of the clinical team and support the mission of clinicians, not the other way around.
A "problem with the interface", indeed.
Also provided is a link to testimonies from witnesses at the house.gov website, which are here [www.drflounder.com].
Notable is the absence of any testimony from IT leadership. The only allusion to IT is in testimony by the doctor who performed the procedures who stated:
"There should be a method of categorizing systematic problems by level of urgency so that serious problems, such as those involving failures of medical equipment or transfer of patient-related data, will receive immediate attention from the proper personnel and be quickly resolved."
Perhaps, but not in this case. A simple phone call to IT should have been adequate to resolve this particular simple problem.
Links to this post [hcrenewal.blogspot.com]
http://www.hcrenewal.blogspot.com/ [www.hcrenewal.blogspot.com]
Feedback from a VA employee who knows what VA retaliation means [via email]:
Mr. Hanafin the front pages of the Philadelphia Inquirer carried this story for most of early July, and states that Dr. Koa, the University of Pennsylvania doctor on loan to the VA was singled out by the VA to take the blame, but most medical professionals realize no one doctor acts alone. In this case, we have the Nuclear Regulatory Commission a federal entity shares part of the blame, and Dr. Richard Whittington, Associate Professor of Radiation Oncology at The Abramson Cancer Center of the University of Pennsylvania, a radiologist all covered up things as well.
Senator Spector et al did NOT speak with the NRC and Whittington at the Senate hearings that were held.
Ironically, as Dr. Koa was being singled out by the VA to take the fall for the Philly VAMC scandal, the female physcians at Bay Pines VAMC were awarded 3.7 million for VA Reprisal and are going back to work there.
What’s been exposed about the VA thus far is only the tip of the iceberg. More examples:
Synthes INC, [us.synthes.com]the global medical device giant, provided spinal cement that killed 4 VA patients with the Spinal cement used illegally. The VA refuses to identify which VAs and 4 dead Veterans. Synthes is l ess than 30 miles from both the Phila [us.synthes.com]delphia and Wilmington VAMCs and only 60 miles from VA Hospitals in Maryland.
In addition, a VA Colorado Technician was charged criminally for giving Veterans and other patients in the area Hepicitus C. The Colorado state attorney general has been looking into this one.
Mr. Hanafin all one needs to do, especially members of Congress on the House and Veterans Affairs Committees, is to review just how hugh the systemic problems with the VA are by getting the VA watch dog daily items.
You mentioned that a few Senators were concerned that the Joint Commission had given the Philly VAMC a clean bill of health and patient safety. If enough peopel within the VA rank and file system who witness wrong doing, unethical, or unsafe medical practices, instead of giving a lame answer to Congress, the Joint Committee would be forced to rethink how they missed the prostate mess in Philadelphia. In fact, they missed it twice.
Feedback from Veterans activist celticblarney via email:
Philadelphia VAMC Radiation errors, BLAMED ON OFFLINE COMPUTER???????????
What WON’T THEY LIE ABOUT????
Make you wonder about the computers they use and the software. If there is a disconnect in the link between a workstation and the mainframe, the workstation would have a pop up notifying you!
Any idiot with two cents worth of brains would know this!
But the Doctor holds the most responsibility, did he not use a scope to monitor his work, actions, progress?
Did they not do any immediate follow-up tests to confirm proper placement? The obvious answer would be no!
The VA needs to stand tall and accept full responsibility for not maintaining properly, well education, highly trained professionals who are FULLY license to practice medicine, technical and nursing staff all with proper credential and highly trained in their fields/profession!
No more passing the buck!
Jim Davis
President
Veterans-For-Change
JDAVIS92840@SBCGLOBAL.NET
http://groups.yahoo.com/group/VETERANS-FOR-CHANGE/
i am trying desperately to get a problem resolved at the VA hospital at huntington wv….i have made complaints to staff, i have complained to the patient advocate….but i am lost…..i feel after my surgery there, i am being targeted for retaliation, after making a complaint against a doctor….i have been humiliated, condenscended too and lied to…i am in so much pain and am losing the use of my hand…i am being treated with coldness and im not being listened to….i hope someone can help direct me to what to do, to get proper treatment
The VA Philadelpjhia will have their day in court about the botched radiation therapy treatments of the prostate gland. The NRC is holding an enforcement conference with the VA to discuss the violations. The hearing is on December 17, 2009 at the NRC Headquarters office in Whiteflint (Rockville), MD. Public is invided to attend.
The doctors that did the botched radiation therapy treatments (Kao and Wittingham) and the three medical physicists (Desobry, Bieda and Lasizrascew) are all a bunch of quacks that work for Hospitals of University of PA and were contractors for the VA Philadelphia. All vets that were affected by these jerks should sue the Hospital of University of PA and the individuals.
The job is outsourced to U Penn rad oncology to provide rad therapy services. It is a shame VA is taking the blame when it should be U Penn. The IT nonsense is always there but the reality is whether a proceedure is done right or not rests on physician. If IT failed to do the job{which is an excuse in all candor} the docs should have stopped doing the proccedure. Can you imagine a cardiac surgeon claiming he is responsible only for doing surgery and is not responsible if the heart lung machine did not work.
The endemic problem at VA is administrative incompetence, cover up and blame someone else not be accountable for their inactions.