[ RadSafe ] Errors expose patients to radiation

[John Jacobus]

First of all, if you have ever worked in accidents do
happen, and is not limited to radiation exposures and
tests.  Technologists are people who make mistakes. 
And we all have stories about what others have done. 
Most facilities have programs in place to evaluate
such errors as mis-alignment of x-ray films, under-
and over-exposures, etc.

Second, using the public limit of 1.0 mSv makes no
sense.  The public limit is from man-made souces and
is EXCLUSIVE of medical exposures.

Third, this is obviously a selected study of reported
incidences only.  

Note:  Some people are annoyed by reports of
"overexposures" to nuclear power workers.  I have the
annoyance to patient overexposure reports.

--- Marcel Schouwenburg
<M.Schouwenburg at TNW.TUDelft.NL> wrote:

> Received through another list (srp)
> 
>
--------------------------------------------------------------------------
> 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.
> 
> . . .

+++++++++++++++++++
"Anyone who has never made a mistake has never tired anything new."
-- Albert Einstein

-- John
John Jacobus, MS
Certified Health Physicist
e-mail:  crispy_bird at yahoo.com

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