[Fwd: Re: medical misadministrations]

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

This is posted with permission of the sender.

Bill





-------- Original Message --------

Subject: Re: medical misadministrations

Date: Wed, 05 Sep 2001 10:43:31 -0500

From: "Ray Wery" <Rayw@waushosp.org>

To: <liptonw@DTEENERGY.COM>



Mr Lipton



I believe that the standard procedure is for the licensee to conduct an

evaluation of all medical misadministrations, analyze causes, and

produce a plan of action that will address the problems found and act on

them.  This will, in most cases, involve everyone involved in the

radiation safety program.

Do you have any information that this does not occur?  

Do you have any information that there are similar incidents occurring

and Radiation Safety personnel are ignoring the issue?  

You seem to have an opinion that "medical HP's" are not providing

professional services because misadministrations occur.  I believe that

you can find information on error analysis of medical misadministrations

if you look.  For example:

Radiation injury from x-ray exposure during brachytherapy localization.

Med Phys 2000 Jul;27(7):1681-1684.  

Thomadsen BR, Paliwal BR, Petereit DG, Ranallo FN



I do not offer any excuses,  radiation safety personnel should assist in

the design of procedures that will ensure that services are delivered as

prescribed.  When problems arise they should design changes to reduce

the likelihood of the problem arising again, while not creating

additional problems.  I do not believe that the identification of

problems indicate that HP's are not doing their job.





Ray Wery, M.S., D.A.B.R.

Medical Physicist/Radiation Safety Officer

Wausau Hospital

Wausau, WI   54401

715-847-2292

rayw@waushosp.org



>>> William V Lipton <liptonw@DTEENERGY.COM> 09/05/01 06:31AM >>>

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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