Had they cared to, the senators could have asked why the radiation-safety committee allowed a computer-interface problem to go uncorrected for a year, jeopardizing patients' treatments. Because of the computer problem, patients' actual postimplant radiation doses were not calculated, so no one knew whether they were getting the prescribed amount.
The NRC, another big player in the mess, says in news releases that it responded "aggressively and decisively to the medical errors" at the VA.
But the commission's public records appear to belie this.
In 2003 and 2005, the NRC investigated two mistakes that the VA reported to it. In both cases, Kao injected half of the radioactive seeds that were meant for the prostate into the patient's bladder. Although a urologist was able to retrieve the errant seeds, the patients' prostate glands obviously received less radiation than prescribed.
The NRC concluded there was no "medical event" -- the regulatory euphemism for medical error -- because the patients' treatment plans were revised to indicate how few seeds actually wound up in their prostates.
In light of the scandal, the NRC has reviewed both cases and concluded they were indeed medical errors.
"It is shocking that a doctor seems to have mishandled procedures" so often, Crane said. "But it is even more shocking that the NRC knew of the problem in 2003, saw it recur in 2005, and didn't take action until 2008."
NRC spokeswoman Viktoria Mitlyng said the agency was responsible for the lax care only to the degree that it misplaced its trust in the VA. When the brachytherapy program was created in 2002, she explained, the NRC allowed the VA to create the National Health Physics Program, which was supposed to monitor treatment and report any problems to the NRC. In effect, the VA was its own watchdog.
"Obviously," Mitlyng said, the National Health Physics Program "didn't work as well as we expected. We will be looking at increasing our own inspections of the VA."
In his testimony, Kao pointed out that he was part of a team -- although he didn't name any teammates. Another part of his defense sounded less persuasive: He said that in 2002, the NRC had no definition of a reportable medical event. He also said the NRC never trained his team "on this issue."
In fact, a simple Google search (NRC report medical event) brings up the reporting rule, which applies to radioisotope medical use in general, not just brachytherapy.
The rule, put into effect by the NRC in 1980, defines a medical event as radiation to a treatment site that deviates by more than 20 percent from the prescribed dose, and radiation to surrounding tissue that is 50 percent or more above the expected dose.
The rule says these errors must be reported to the patient within 24 hours and to the NRC within 15 days.
Kao also contended that the definition of a medical event keeps evolving and is "a subject of debate" -- which is true.
