medical misadministrations

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

I'll dare to use the "e" word, again.  There seems to be an epidemic of

medical misadminstrations, that seem mostly due to human error:



8/7/96 - 10/18/00 - Providence Hospital, Washington, DC - 14

misadministrations where approximately 3000 rads was delivered with

1200-1500 rads prescribed with a Sr-90 eye applicator.



8/31/01 - St. Mary's Hospital, Rochester, MN - delivered dose from Co-60

gamma knife 39% greater than prescribed due to timer entry error.



8/31/01 - University of Kansas Hospital, Kansas City, KS - Technician

administered wrong radionuclide to patient.



(I'm not counting the 8/21/01 misadministration at Wyoming Medical

Center, where the misadministration resulted from highly technical

issues.)



I'd be interested to know whether the medical hp's are doing anything to

improve human performance in this area.



BTW:  I don't buy the previous excuses, when I raised this issue, that,

"It's not my job."  According to the HPS Prospectus, "The Society is a

professional organization whose mission is to promote the practice of

radiation safety..."  This seems to be one area where "the practice of

radiation safety" seems to need improvement.



The opinions expressed are strictly mine.

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



Bill Lipton

liptonw@dteenergy.com





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