Report Summary

Title: Healthcare Inspection - Follow-Up Assessment of Radiation Therapy, VA Long Beach Healthcare System, Long Beach, California
Report Link: http://www.va.gov/oig/pubs/VAOIG-13-00696-254.pdf
Report Number: 13-00696-254
Issue Date: 7/31/2013
City/State: Long Beach, CA
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: Healthcare Inspections
Release Type: Unrestricted
Summary: The OIG conducted a review of new allegations and a follow up of its March 2011 report on radiation therapy (RT). We found that for three prostate cancer patients treated in 2009 and 2010, therapists did not follow local policy when shifts in the field of delivered radiation occurred. However, appropriate corrections occurred and despite shifts, all patients received full treatment to tumor containing tissue. Additionally, there was no evidence of complications attributable to errors in delivery of radiation therapy. A patient with vocal cord cancer had transient skin abnormalities resulting from misdirection of the radiation beam. This was corrected with no long-term adverse consequences and radiation was consistently delivered to the target lesion. For 27 patients treated in 2012, whose care we evaluated, radiation treatment was appropriate but in some cases treatment was delayed. Electronic health record documentation was deficient. This deficiency had been cited in the 2011 OIG report and in two accreditation surveys.
We found improvements in quality management, but adverse event reporting did not occur as specified in the 2011 facility response action plan. Further, the facility was unaware of a radiation therapy complication managed at a referring facility five months after completion of radiation treatment.
We recommended that radiation therapists adhere to local policy when shifts in the field of delivered radiation occur, deficiencies in patient care documentation are addressed, adverse events are reported as specified in the facility’s 2011 report action plan, and radiation complications managed at referring facilities are reported to the facility that provided the radiation therapy.