Re: therapy accidents

["J. J. Rozental" <joseroze@netvision.net.il>]

There are many documents relating radiation therapy incidents and accidents.
In the NRC Site it is  possible to find copious information on
misadministration and mismanagement. However I would like to recommend two
documents

a) ACCIDENTAL OVEREXPOSURE OF RADIOTHERAPY PATIENTS IN SAN JOSE, COSTA RICA


This report summarizes the assessment made of an accidental overexposure of
radiotherapy patients that occurred at the San Juan de Dios Hospital in San
Jos?, Costa Rica, in August and September 1996. The assessment was carried
out by an Expert Team convened by the IAEA in July 1997 at the request of
the Government of Costa Rica. The findings of the Expert Team's assessment
are presented in two parts: (1) an evaluation of the doses to patients by
analysing the treatment records and physical measurements; and (2) a medical
examination of patients, together with the autopsy findings for those who
died. Thirty cross-sectional images are reproduced that show the dose
reconstructions made for some of the patients. The purpose of the report is
to foster information exchange with a view to preventing similar accidents
elsewhere in the future.

Contents: Contents: Preface; Executive Summary; 1. Overview of radiotherapy
and radiation protection; Part I. Background; 2. History of the accident; 3.
Expert Assessment organized by the IAEA; Part II. Findings of the Expert
Team; 4. Assessment of the dosimetry and the status of the equipment and the
facility; 5. Medical effects of radiation exposure of the patients; Part
III. Conclusions and recommendations; 6. Conclusions and recommendations;
Appendix I: Results of the dosimetric findings and the status of the
equipment and the facility; Appendix II: Data on patients; Annex: Records on
the participation of the San Juan de Dios Hospital in the IAEA/WHO TLD
postal dose quality audit; Addendum: Reconstruction of the doses to normal
tissue for patients with marked adverse effects.

Obs: - Source Co-60, 60% overdose, 115 overexposure, 13 deaths to the end of
1998

b) The Radiological Accident in Zaragosa (Spain), 1990, in Spanish

Source Accelerator, dose unknown, 27 overexposure, 11 deaths

Jose Julio Rozental
joseroze@netvision.net.il
Israel










----- Original Message -----
From: Chris Alston <alstonc@odrge.odr.georgetown.edu>
To: Multiple recipients of list <radsafe@romulus.ehs.uiuc.edu>
Sent: Friday, April 21, 2000 2:50 PM
Subject: therapy accidents


> >From: Wesley Wooten <wooten@UCSFRESNO.EDU>
> >
> >>
> >>Can anyone please direct me to a compilation of radiation therapy
> >>accidents?
> >
> >There is a fascinating and detailed discussion of the Therac-25
> >misadventure (June 1985 to Jan 1987) contained in appendix A to the
> >text:  _Safeware_System_Safety_and_Computers, by Nancy Leveson,
> >Addison-Wesley Publishing, 1995
> >
> >-------------------------------------------------------
> >Wesley W. Wooten, Ph.D.
> >Saint Agnes Medical Center (200)
> >1303 E. Herndon Ave.
> >Fresno, CA  93720
> ************************************************************************
> The RADSAFE Frequently Asked Questions list, archives and subscription
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