[ RadSafe ] The French health ministry has ordered an independent inquiry into the affair.

[McMahan, Kimberly L.]

The IRSN investigative report, in French, can be found at:
http://www.irsn.org/document/files/File/Internet/Actualites/synthese_mis
sion_radiotherapie_epinal.pdf

Unless I mis-read the document (definitely a possibility), the software
was not the direct cause, and these were not diagnostic "scans," they
were conformational radiotherapy treatments. Treatment planning
decisions were made by the medical staff at that hospital to deliver
higher doses in order to control the prostate cancers. The typical
protocol calls for a dose to the prostate of 70-74 Gy, while for these
patients the decision was made to deliver 78 Gy. This higher dose
over-exposed the nearby rectal tissue, with severe consequences. There
is some discussion in the report about the decision to effectively
engage in a clinical trial, and without informing the patients of
increased risks.

Kim McMAHAN  ORNL External Dosimetry


-----Original Message-----
From: radsafe-bounces at radlab.nl [mailto:radsafe-bounces at radlab.nl] On
Behalf Of Jose Julio Rozental
Sent: Wednesday, March 28, 2007 12:50 PM
To: radsafe at radlab.nl
Subject: [ RadSafe ] The French health ministry has ordered an
independent inquiry into the affair.

Dear colleagues, especially from France,

Who can comment about the subject 

Jose Julio Rozental
joseroze at netvision.net.il
Israel

One dead, 13 injured in X-ray blunder at French hospital
http://www.qldcancer.com.au/pdf/November.pdf

AFP via Yahoo! News - 12-Oct-06 

Agence France-Presse reported that one person died and 13 others fell
sick after they were exposed to excessive doses of X-rays as they were
being scanned for prostate cancer at Epinal Hospital near Strasbourg in
eastern France. 

The accidents occurred between May-04 and May-05, where staff misused a
new software programme that had been installed in the X-ray unit. The
Lorraine Regional Hospital Agency said that 23 patients received
excessive doses of radiation, and the 13 who fell ill suffered from
rectal inflammation and needed surgery to fit an artificial anus. 

The French health ministry has ordered an independent inquiry into the
affair. 
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