Another unbelievable report in the Philadelphia Inquirer about the VA prostate brachytherapy debacle. As I wrote before, 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. It can be difficult at times to get two computer systems talking to one another, especially if they are from different vendors. However, it turns out the problem was more mundane.
As MedInformaticsMD posts, the issue was that a request to install a network jack was ignored for year. It’s hard to believe that this whole mess could arise from the failure to have a place to plug a computer into the network, but it seems to be the case. There’s a lot of good analysis over at Health Care Renewal, where MedInformaticsMD makes the point that too often in cases like these, IT is not held to account for their service failures.
In other Philadelphia VA news, the full House Veterans’ Affairs Committee held their hearings on the issue this past Wednesday. I’ve been busy and haven’t had time to watch the webcast, but you can see it here, along with written statements from the witnesses.
