[ RadSafe ] Medical incident (Bill Lipton)

Robert Atkinson robert8rpi at yahoo.co.uk
Fri Sep 6 01:29:25 CDT 2013

As a non-USA list member, the thing that surprises me is the apparent disparity in punishment for medical misadministraion compared to portable nuclear gauge incidents. Relatively unskilled technicians working in poor, dangerous conditions on construction sites can (and do) loose their jobs through "loosing control" of a guage for maybe only a couple of minutes with the only result a damaged gauge. Medical staff seem to face little punishment for gross errors made in a clean, low pressure environment. Don't get me wrong, I  don't think either extreme is correct, but it looks to me that some equality should apply. 
I also find it mildly amusing that a medical misadministration of tens of millirads is "insignificant" in relation to the intended dose, but a fraction of that is a serious incident in a lab / power / insustrial context.
Robert Atkinson CEng.

 From: Peter Crane <kinderhook46 at yahoo.com>
To: radsafe at health.phys.iit.edu 
Sent: Friday, 6 September 2013, 1:15
Subject: [ RadSafe ] Medical incident (Bill Lipton)

This thread began with an incident in Oregon in which, depending on how you look at it, a patient got the wrong pharmaceutical or the right pharmaceutical went to the wrong patient. This was first described by NRC as a reportable event, but a day later, it was classified as non-reportable. I checked with the NRC today and ascertained that the reason that this was determined to be non-reportable was the low dose to the patient from what was a diagnostic procedure. (Kent Lambert surmised rightly that this was the case.) Still, it is a sign of a failure of QA, as Bill Lipton points out, and as such, raises a red flag. A licensee that is sloppy about low-dose diagnostic procedures may be equally sloppy about high-dose therapeutic procedures.

The statement of Matt Williamson of Memorial Sloan-Kettering Cancer Center that he counsels people "NEVER to call the regulator ASAP" sent me to the NRC's regulations. 10 CFR 35.3045 says that such errors as administering the wrong radioactive drug to a patient, or administering a dose to the wrong patient, must be reported to the NRC by the next calendar day. I hope that doesn't mean that Matt has been telling people at MSKCC to disregard the NRC requirement of next-day reporting.  

The point of requiring such prompt reporting is that you get to the regulators and the referring physician quickly and tell them of the event, with the explicit understanding that this is preliminary and that the details will have to be sorted out later. Sometimes this may call for immediate regulatory action, sometimes not. In this case, the fact that the event report was retracted a day later is not a sign that the system failed, but on the contrary, that it worked.    

MSKCC is a world-class facility, probably the place where I would tell any loved one in New York to go for cancer care, but that doesn't mean that it is exempt from the regulations that apply to every other licensee.  

-- Peter Crane, NRC Counsel for Special Projects (retired)    

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