The V.A. Cancer Debacle

I've been thinking all day about what to write about the shocking New York Times expose of the cancer unit at a Philadelphia Veterans Affairs hospital, where a clearly irresponsible, though highly pedigreed contract doctor botched prostate cancer treatments for all but a few of 92 veterans who received bad implants. But all I can really come up with to say is that fixing this list of problems seems to be a decent place to start:

Peer review, a staple of every good hospital, in which colleagues examine one another's work, did not exist in the unit. The V.A.'s radiation safety program; the Nuclear Regulatory Commission, which regulates the use of all nuclear materials; and the Joint Commission, a group that accredited the hospital, all failed to intervene; either their inspections had been limited or they had not acted decisively upon finding problems.

Over all, the implant program lacked a "safety culture," the nuclear commission found. Dr. Kao and other members of his team, the commission said, were not properly supervised or trained in what constitutes a substandard implant and the need to report it.

And for the love of all that is decent, folks should have to be certified in procedures, whether they involve radiation or not, before they start performing them en masse.