[ RadSafe ] " -overradiated by CT scans" Some useful references on the topic of errors in medical radiation procedures

parthasarathy k s ksparth at yahoo.co.uk
Wed Feb 10 19:09:48 CST 2010

Mike Brennan,

The publicity surrounding the infamous CT perfusion study and the recent NYT series on radiation mistreatments highlighted the need for eternal vigilance.

Discussions on LNT, radiophobia, statistics of mistreatments etc offer no solace to the victims.We must have zero tolerance to errors in medical radiation procedures.

 Holmberg and McClean stated thus in a review published in the Journal of Radiotherapy in Practice (2002) 3:3;13-25:

"For each reported actual treatment error originating in the
treatment preparation chain, 13.8 near misses were found by primary and
secondary checking and thereby prevented from becoming actual errors.
The total frequency of near misses was 34.4 per 1000 treatment plans.
The primary checkers reported 23 types of errors for manual treatment
plans (without dose distribution) and 30 types of errors for computer
plans. Computer plans also showed a near miss rate that was 42% higher
than for manual plans. The high ratio of near misses per actual error
demonstrates an effective error prevention system, independent of the
quality of the initial treatment preparation. Complex treatment plans
were shown to be particularly error-prone, thereby requiring extra
vigilance when checking."

In 2000, the International Atomic Energy Agency published details of 94 incidents in its Safety Reports No. 17 titled Lessons Learnt from Accidental Exposures in Radiotherapy. Every radiation oncologist must read this book. 

In 2000, a publicationfrom the International Commission on
Radiological Protection (ICRP) listed some incidents from the U.S.,
Germany, the U.K., Spain and Costa Rica. Over 1960 patients got exposed
to excessive doses during 1974-1996. 

Besides these, IAEA has provided excellent training material on the topic in the following URL:
Every one carrying out radiotherapy must read them. 

We were aware of these problems for decades. The power of the media (the NYT articles) caught every one's attention


From: "Brennan, Mike (DOH)" <Mike.Brennan at DOH.WA.GOV>
To: radsafe at radlab.nl
Sent: Wed, 10 February, 2010 22:38:00
Subject: RE: [ RadSafe ] " -overradiated by CT scans"

Hi, Howard.  

You are, of course, completely correct that there are many, many, things where an 8x over recommended dose/amount/time could have deadly effects.  I also agree without reservation that radiophobia is a counterproductive attitude that has almost certainly cost more lives than it has saved, especially when it has been expanded to industrial and environmental policy.  

That being said, there is no excuse, none whatsoever, for patients to get the wrong exposure/medicine/treatment.  The fixes to prevent these are administrative and technical, with all the tech being well established and many easier to use than the current systems.  Much can be done with check lists, where people have to read and check each step (and no, it doesn't slow down the process, not when you factor in even the rare time that some step gets missed, and corrective action needs to be taken).  Another fix would be to include an RF tag in the patient ID bracelet, and use it to make sure that the right prescriptions, treatments, etc, go to the right patients.  

I consider this to be more of a medical industry failure than a radiation industry failure.

-----Original Message-----
From: radsafe-bounces at radlab.nl [mailto:radsafe-bounces at radlab.nl] On Behalf Of HOWARD.LONG at comcast.net
Sent: Wednesday, February 10, 2010 8:35 AM
To: Kyle Harness
Cc: radsafe at radlab.nl
Subject: [ RadSafe ] " -overradiated by CT scans"

" NY Times -  more than 300 patients in four hospitals were overradiated by powerful CT scans used to detect strokes. The overdoses were first discovered last year at Cedars-Sinai Medical Center in Los Angeles, where patients received up to eight times as much radiation as intended. 

"The errors occurred over 18 months and were detected only after patients lost their hair." 

What would happen with 8x sunbath or UV tanning salon exposure or dose of coumadin (rat poison taken by millions to save thousands of lives from clots)? Smell burning skin or write obituaties, instead of hair loss! 

This radiophobia is pretext to expand larceny of government, which now increases salaries while private pay is cut! I believe those hospitals will suffer reputation harm far more safety-inducing than oppressive "oversight". 

How about the millions of people scared out of CTs in cancer-inhibiting doses that would detect unsuspected kidney cancer, dubious brain clots, etc. (10 to100 mSv)? 

Howard Long, family doctor, Pleasanton CA 
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