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RE: medical misadventures
A good part of being a good HP has nothing to do with the actual risk to the
person, but good regulatory compliance. We all fail as individuals at
times, but there is no room for indifference to regulations that we don't
think are necessary. You can't just practice human error reduction when you
think it is necessary. It needs to have been done repetitively until it is
a habit, then you'll still use conservative decision making on a bad day.
Perhaps the reactor folks have been beat up so much over the years for 1 or
2 millirem, but I believe the risk does go down if a facility has an active
human error reduction program.
Glen Vickers
> -----Original Message-----
> From: Perrero, Daren [SMTP:Perrero@IDNS.STATE.IL.US]
> Sent: Thursday, September 06, 2001 1:29 PM
> To: radsafe@list.vanderbilt.edu
> Subject: RE: medical misadventures
>
> 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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