[ RadSafe ] Medical Incident

Franz Schönhofer franz.schoenhofer at chello.at
Thu Sep 5 10:15:29 CDT 2013

Dear Bill,

Your own motto "It's not about dose, it's about trust" gives an excellent 
answer to this issue!

In German medical doctors are called "just for fun" "gods in white". This is 
funny, but has a deeper meaning, namely that medical doctors are regarded as 
and should be reliable and trustworthy. Doctors who give wrong medication 
and/or doses are no way reliable and trustworthy. Since I spent (to) many 
weeks recently in hospital I know, that the nurses, who adminster infusions, 
drugs and injections have strict rules, what they are allowed to do and what 
they are not. Medical doctors are the finally responsible persons.

Whatever the wrongly adminstered dose would be - between negligble and 
deadly - this is a serious violation and should be punished accordingly. 
This means that "neglectable" dose is no excuse for failures in the hospital 
BTW I received dozen(s?) of X-rays of my broken toes during the last six 
months and was always happy to hear that the healing is well progressing. I 
never asked about the dose I received......

Best regards,


-----Ursprüngliche Nachricht
From: William Lipton
Sent: Thursday, September 05, 2013 3:19 PM
To: willim01 at mskcc.org
Cc: radsafe
Subject: Re: [ RadSafe ] Medical Incident

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 ...and now the event has been retracted, not reportable.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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