RE: medical misadventures

["Perrero, Daren" <Perrero@IDNS.STATE.IL.US>]

Bill



The other side of this argument is that a fair number of human errors that

end up as medical misadminstrations are violations of regulations that have

no place being burdened upon licensees in the first place. No "major event"

has even occurred. The "errors", in fact, have no impact on the health of

the patient involved. The range of effectiveness for most therapeutic doses

are enormous and whether you are off by 20% or more is irrelevant to the

outcome, or better yet the administration of radiation is a means of

providing "additional assurance" that the main treatment method (i.e.,

surgery) is successful, yet by regulation the "error" is a reportable

misadministration. No harm, no foul, I say! 



The rad protection program at the facility is, more often than not, just

fine and the misadministration is not a valid indication of the quality of

work being done by the Med Physicist/RSO at these facilities.  Med HP's

spend their entire day trying to improve "human performance", but like

everyone else they have to allocate limited resources.  I would rather see

them spending their time with the CT Scanner, Mammography Unit and LINAC and

other X-ray sources since there are far more medical procedures conducted

with these forms of radiation than in the busiest Nuc Med Dept.



If its really about trust, and not dose, then I suggest the medical folk

stop being required to wave red flags when the patient impact is negligible

in the first place.



 



more than ever, the thoughts expressed are mine, mine, all mine! I'm with

the government, I'm here to help........



Daren Perrero, Health Physicist



perrero@idns.state.il.us



 



 



 



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

From: William V Lipton [mailto:liptonw@DTEENERGY.COM]

Sent: Thursday, September 06, 2001 6:18 AM

To: julian ginniver; radsafe@list.vanderbilt.edu

Subject: Re: medical misadventures





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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