RE: medical misadventures

["Phil Hypes" <laradcon@HOTMAIL.COM>]

What's reasonable in a nuclear reactor setting isn't necessarily reasonable 

in a nuclear medicine setting.  For therapeutic doses of radioactive 

material, a second set of eyes is already required.  For the vast majority 

of diagnostic procedures, the risks are trivial compared with the risks of 

transporting the patient to the facility.  I don't necessarily agree that 

more regulations and oversight are required purely becuase mistakes have not 

been 100.0000% eliminated.



Finally, when I was an RSO at a hospital, I took it upon myself to make sure 

the nuc med techs were aware of mistakes made at other institutions, and had 

the opportunity to learn from them.  Of course, we never had such 

opportunities at our hospital while I was there ;-) !



Phil Hypes

Los Alamos Radiation Consultants

laradcon@hotmail.com

505.920.9712







>From: glen.vickers@EXELONCORP.COM

>Reply-To: glen.vickers@EXELONCORP.COM

>To: lodhil@MAIL.TEMPLE.EDU, liptonw@DTEENERGY.COM, 

>julian.ginniver@lineone.net,        radsafe@list.vanderbilt.edu

>Subject: RE: medical misadventures

>Date: Thu, 6 Sep 2001 12:00:56 -0500

>

>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





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