Panama Event

[William V Lipton <liptonw@DTEENERGY.COM>]

All medical HP's should read NRC Information Notice 2001-08, "Treatment

Planning System Errors Result in Deaths of Overseas Radiation Therapy

Patients."  This is the best available information from the ongoing

investigation.  It seems that software errors and less than adequate

Quality Assurance procedures resulted in overexposures to 28 radiation

therapy patients, and that up to five of these patients died as a

result.



IMHO two lessons are clear:



(a) The medical use of byproduct material needs continuing NRC or

Agreement State regulation.  Although the events occurred in Panama, the

therapy devices and software involved were from a U.S. company.  IMHO,

without our regulatory system we would be seeing similar events in the

U.S.



(b) Any required use of SI units must be approached with great caution.

The use of SI units in place of the customary units was listed as a

contributing factor in these events.



The opinions expressed are strictly mine.

It's not about dose, it's about trust.



Bill Lipton

liptonw@dteenergy.com



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