[ RadSafe ] Medical Incident
franz.schoenhofer at chello.at
Thu Sep 5 10:15:29 CDT 2013
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......
From: William Lipton
Sent: Thursday, September 05, 2013 3:19 PM
To: willim01 at mskcc.org
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!
It's not about dose, it's about trust.
On Sep 5, 2013 8:48 AM, <willim01 at mskcc.org> wrote:
> ...and now the event has been retracted, not reportable.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
> 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
> trend - 2 errors in one) with their program.
> Load up the gov't van! We're goin' inspectin'!
> Matt Williamson
> willim01 at mskcc.org
> Please note that this e-mail and any files transmitted from
> Memorial Sloan-Kettering Cancer Center may be privileged,
> and protected from disclosure under applicable law. If the reader of
> this message is not the intended recipient, or an employee or agent
> responsible for delivering this message to the intended recipient,
> you are hereby notified that any reading, dissemination,
> copying, or other use of this communication or any of its attachments
> is strictly prohibited. If you have received this communication in
> error, please notify the sender immediately by replying to this
> and deleting this message, any attachments, and all copies and
> from your computer.
You are currently subscribed to the RadSafe mailing list
Before posting a message to RadSafe be sure to have read and understood the
RadSafe rules. These can be found at:
For information on how to subscribe or unsubscribe and other settings visit:
More information about the RadSafe