[ RadSafe ] Errors expose patients to radiation

[Marcel Schouwenburg]

Received through another list (srp)

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Sunday Herald reports Errors expose patients to radiation

http://www.sundayherald.com/51922

MORE than 500 people have been accidentally overexposed to radiation in 
hospitals across Scotland in the past 10 years.
More than four-fifths of them were patients having X-rays, CAT 
(computer-assisted tomography) scans or radiation therapy, while the rest 
were hospital staff. The accidents were caused by human errors, procedural 
mistakes, equipment failures and spillages.

In a few cases, unborn babies were inadvertently given large doses of 
radiation far in excess of the safety limits. In other instances, people 
were wrongly X-rayed, given repeat scans or badly injected.

Hospitals have also lost or mislaid radiation sources . All sources are 
meant to be secured to prevent them being stolen by terrorists and used in 
"dirty bombs".

The revelations, contained in a new NHS study, have worried politicians, who 
are calling for action to cut the number of accidents. The government's 
radiation watchdog, the Health Physics Service, says it is important to keep 
radiation doses as low as possible, especially for children and pregnant 
women.

Radiation is a common tool in medicine throughout the developed world. 
X-rays and CAT scans help diagnose a wide range of health problems, while 
radioactive chemicals are put in the body as tracers and used, externally 
and internally, to destroy cancers. However, all radiation is potentially 
dangerous, and extra doses can increase the risk of cancer.

Colin Martin, head of the Health Physics Service for NHS hospitals in the 
west of Scotland, has analysed 606 incidents reported since 1995.

In 423 incidents patients were overexposed to radiation, and in 114 cases 
hospital staff were overexposed or contaminated. The commonest reason was 
staff error, followed by equipment failure. In more than one in 10 cases the 
wrong patient was scanned or treated . Sometimes the wrong part of the body 
was X-rayed .

Patients were also given repeat scans because staff forgot to change the 
film, machines were left on or computers crashed. Staff were contaminated by 
slips while giving injections, or by urine or vomit from radiotherapy 
patients.

In a third of the incidents the radiation dose was above the annual safety 
limit for the public of one mSv (milliSievert). In half a dozen cases the 
doses were more than 20 times in excess of the limit. Four of the highest 
exposures were to pregnant women.

In most cases, patients were probably informed about the errors at the time. 
Martin, who is based at Gartnavel Royal Hospital in Glasgow, pointed out 
that the mistakes represented a very small fraction of the million or more 
radiation procedures carried out in the west of Scotland every year.

"There is no reason to suspect that the number of radiation incidents in the 
west of Scotland is different from that in other parts of the UK," he told 
the Sunday Herald.

"By encouraging a more open reporting system, the Health Physics Service is 
able to investigate the causes of incidents, so that procedures can be 
improved. The risks of any health consequences from exposure to radiation at 
these levels are very low."

But Dr Eleanor Scott MSP, health speaker for the Scottish Green Party, 
stressed that "any unnecessary exposure to radiation should be avoided".

The study is being published in next month's British Journal of Radiology.

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Marcel Schouwenburg - RadSafe moderator & List owner
Head Training Centre Delft
National Centre for Radiation Protection (Dutch abbr. NCSV)

Faculty of Applied Sciences / Reactor Institute Delft
Delft University of Technology
Mekelweg 15
NL - 2629 JB  DELFT
The Netherlands
Phone +31 (0)15 27 86575
Fax     +31 (0)15 27 81717
email   m.schouwenburg at tnw.tudelft.nl