[ RadSafe ] Medical Incident

[William Lipton]

There's nothing wrong with reporting an event and later retracting the
report after further evaluation, especially when you consider the
consequences of not filing a timely report for a reportable event.  Reports
and later retractions are common with power reactors, and I think the NRC
appreciates the "heads up."

The most important thing, however, is effective corrective action.  I got
the impression that, in this case, the sole corrective action was a rad
safety committee meeting.  They need a root cause investigation and
meaningful corrective actions.  The low doses are not relevant.  Dumb luck
is not an effective QA program!

Bill Lipton
It's not about dose, it's about trust.
 On Sep 5, 2013 8:48 AM, <willim01 at mskcc.org> wrote:

> http://www.nrc.gov/reading-rm/doc-collections/event-status/event/en.html
>
> ...and now the event has been retracted, not reportable.
>
> I agree with all of your concerns regarding medical events and errors.
>
> However, I instruct many people NEVER to call the regulator ASAP.  The
> event must be reviewed to ensure it truly is reportable.  There are other
> mechanisms to handle errors internally (kind of a new philosophy?).  We
> brought the idea to our hospital from nuclear power and root cause analysis.
>
> That being said, the 'as big' an error here is reporting an event that
> wasn't reportable, which in our (NPP) minds, indicates a serious concern (a
> trend - 2 errors in one) with their program.
>
> Load up the gov't van!  We're goin' inspectin'!
>
>
> Matt Williamson
> willim01 at mskcc.org
>
>
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