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Re: [Fwd: Re: medical misadministrations]
In fact, when I brought up this issue, earlier, I remember some responses from
hp's indicating that they did not consider preventing medical
misadministrations to be their responsibility.
I'm sure that misadministrations are investigated, but the continuing
occurrence of these events indicates that not enough is being done. A good
program must be proactive as well as reactive. Also, and this is pure
speculation on my part, I suspect that hospitals do not have an adequate
program to share information on these events. Thus, each licensee has to
learn its lessons the hard way. (The easy way is when it happens to someone
else, the hard way is when it happens to you.)
The opinions expressed are strictly mine.
It's not about dose, it's about trust.
Bill Lipton
liptonw@dteenergy.com
William V Lipton wrote:
> 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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