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RE: medical misadventures
Mr. Perrero:
I wish to respond to what I see as two serious problems with your
statements.
1. "...whether you are off by 20% or more is irrelevant to the outcome...
Your reply seems to indicate that you are discussing therapeutic doses of
radiation.
The radiation administered to a patient during therapy has been carefully
calibrated from more than 70 years of clinical experience. There is a
delicate balancing act the physician must perform. Too little dose and the
tumor returns; too much and the patient suffers serious injury, perhaps even
death. The dose response curve for unacceptable consequences is steep.
Depending on the part of the body treated, as little as a 10% increase in
dose, in a population of patients, may result in a rise in the frequency of
unacceptable injuries from 5% of patients to 50%. Therefore, the margin for
error is narrow.
2. "the misadministration is not a valid indication of the quality of work
being done by the Med Physicist/RSO at these facilities"
It has been my experience (as a hospital RSO) that misadministrations almost
always have a clear root cause that needs to be addressed immediately. They
usually revolve around one or more of the following;
a. Inadequate or missing procedures
b. Inadequate training
c. Inadequate supervision
d. People "too busy" to follow proper procedures
Since the medical physicist and/or RSO is involved in one or more of these
areas, I strongly disagree that a misadministration is not a valid
indication of the quality of work. It may be that the root cause was beyond
the immediate control of the physicist or RSO, but that does not mean that
there are not changes that can be made to prevent a recurrence.
Thomas L. Morgan, Ph.D.
Director, Health Physics
Radiation Safety Officer
Isotope Products Laboratories
24937 Avenue Tibbitts
Santa Clarita, CA 91355
661-309-1033 (voice)
818-558-4087 (fax)
-----Original Message-----
From: Perrero, Daren [mailto:Perrero@IDNS.STATE.IL.US]
Sent: Thursday, September 06, 2001 11:29 AM
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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