RE: medical misadventures

[glen.vickers@EXELONCORP.COM]

I think what Bill is getting at is that the "corrective actions" are

ineffective.  In the nuclear power business we have another person

independently verify key variables before proceeding with a task.  We do

peer checks or independent verifications for many things that do not

directly impact dose to the public.  As a minimum, you would think that any

activity that directly impacts dose to a person would be verified by another

person.  Even set some minimum dose threshold for a verification.



We're all sure that those who committed the error had good intentions and

we're all sure that some form of independent verification would probably

prevent the occurrence of >95% of these problems.



I think the biggest barrier to performing such a simple and effective

preventive action is cost.  The cost of having another person around

periodically for routine verifications is not seen as being worth the

benefit.  It takes something like fines from the NRC to make the

cost/benefit calculation worthwhile.  I'm sure the insurance companies also

wouldn't want to give the provider the extra $20 for performing the

verification, but that would probably be a good place to start.  



Glen Vickers



> -----Original Message-----

> From:	Lily Lodhi [SMTP:lodhil@MAIL.TEMPLE.EDU]

> Sent:	Thursday, September 06, 2001 10:24 AM

> To:	liptonw@DTEENERGY.COM; julian.ginniver@lineone.net;

> radsafe@list.vanderbilt.edu

> Subject:	Re: medical misadventures

> 

> Dear Bill:

> 

> Thank you for sharing the information regarding medical mishap.  I

> immediately shared them with my medical colleague.  As RSO I strongly

> believe that the review of this type of event would teach the staff to be

> more diligent in performing their routine repeated tasks. In addition I

> discuss the related events with the staff during my annual Radiation

> Safety Training. We discuss the event and talk about how it could be

> avoided which in many cases it takes couple of seconds of their time to

> review their work before they proceed.  So far this method has been

> working. 

> 

> Regards,

> 

> Lily Lodhi

> 

> 

> >>> William V Lipton <liptonw@DTEENERGY.COM> 9/6/2001 7:18:16 AM >>>

> Virtually every major event at a power reactor is reviewed by other

> power reactors to determine whether they are vulnerable to a simlar

> event, and corrective actions are taken, as appropriate.  I don't see

> that happening in the medical hp community.  Informal information

> exchange is important, but you should also have procedures that assure

> documented reviews of key events.

> 

> I didn't intend to imply laxity, except for those who claim, "It's not

> my job.", or "I don't check the calculations, I just sign off on them!"

> 

> In the power reactor industry, this would be considered an "opportunity

> for improvement."  And, yes, "I'm here to help you."

> 

> The opinions expressed are strictly mine.

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

> 

> Bill Lipton

> liptonw@dteenergy.com 

> 

> julian ginniver wrote:

> 

> > Bill,    I find that I can't agree with your suggestion that because

> > event occur in the medical applications of radiation and radioactive

> > material that these events are indicative of laxity on the part of our

> > colleagues in this area.  Within the nuclear industry there are

> > ongoing efforts to highlight the lessons we can learn from the events

> > that continue to occur.  Does this indicate a lack of diligence on our

> > part?  We can only take heart from our obvious desire to improve and

> > use formal and informal routes (such as Radsafe) to do what we can to

> > highlight these events.  What I would like to know is if, as you

> > suggested, these events are not widely promulgated through the medical

> > profession.  As you so rightly pointed out we should endevour to make

> > everyone aware of the lessons that can be learnt. Best

> > Regards            Julian Ginniver

> 

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