[ RadSafe ] Incidents in French Hospital

Peter Thomas Peter.Thomas at arpansa.gov.au
Wed Oct 18 18:28:30 CDT 2006

Ed, Jeff and list,

The website of the French Health Ministry www.sante.gouv.fr has a
sidebar titled "Alertes sanitaires" (right hand side) and under the date
12/10/06 (that's 12th October 2006 for those who express dates in one of
the other ways) there is "Accidents de radiotherapie au centre
hospitalier d'Epinal (Vosges)".  This links to a press-release
http://www.sante.gouv.fr/htm/actu/31_061012.pdf (there's an underscore
hidden in that link after 31 and before 061012).  The release is in
French of course and mine is practically non-existent so I ended up
cutting and pasting the text into the Google translator.  It would
appear to perform a rather literal translation and produces interesting
English sentences which nonetheless still pass the grammar checker in
Microsoft Word.

First of all this is about radiotherapy for treatment of prostate
cancer.  When I read the article in TodayOnline I thought it was talking
about some sort of diagnostic test, making the whole death and injury
part sound a bit of a stretch.

The press release says that 23 patients were overexposed by around 20%
between May 2004 and May 2005.  One patient's death (on June 25, 2006)
has been attributed/linked to the overexposure, 3 others have died since
receiving the treatment but their deaths have not been linked with the
overexposure.  13 patients have had rectal complications (the
TodayOnline article mentioned requiring a prosthetic anus).  6 patients
have not shown any symptoms.

A whole chain of regulators/investigators has got involved since the
official notification on July 4, 2006.  The press-release lists three
findings from the initial investigation: (1) over-exposures resulted
from an error in the treatment planning software, (2) staff training in
the use of the software was not sufficient, (3) information on the
patients involved was not complete.  A full report is expected by the
end of the year.

The affair also seems to have engendered a move to formalise reporting
procedures for such incidents and a declaration of roles and
responsibilities.  Perhaps someone better placed than I can comment on
the bureaucratic aspects.  I believe I read somewhere that the ASN
(l'Autorite de surete nucleaire [apologies for the lack of correct
diacritical marks]), which had until then been only concerned with
nuclear power, took over more general radiation protection
responsibilities in 2002.

Corrections and additions welcome

Peter Thomas
Medical Physics Section

Ed Mok wrote:

Does anybody have any further detail about this?

Ed Mok

Jeff Terry wrote:

1 killed, 13 injured in X-ray mishaps at a French Hospital.


The incidents took place between May 2004 and May 2005, improper use  
of software blamed.


Important: This email (including any attachments) is intended only for the use of the
addressee and may contain confidential and / or privileged information.  
If you are not the intended addressee, you are prohibited from relaying on, distributing, disclosing, 
copying or in any other way using any information in this email. If you have received this email in error, 
please notify the sender immediately and erase all copies.
Any opinions expressed in this email are not necessarily held or authorised by Australian Radiation 
Protection And Nuclear Safety Agency (ARPANSA).
Whilst ARPANSA has taken all reasonable steps to ensure this is email is virus free,
it accepts no responsibility and makes no warranty. The recipient should take its own steps to ensure
there is no virus and bears full responsibility for any use.

Australian Radiation Protection And Nuclear Safety Agency

More information about the RadSafe mailing list