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RE: medical misadventures
Bill,
A couple of points. I do believe that the number of 98,000 deaths has
recently put into question. It is probably too high by a factor of three.
One problem is the people who die in hospitals are very sick or badly
injured. Sometimes, for what they are being treated, like cancer, is not
what kills them, a failing heart.
Consider that there are 8,200,000 administrations of radionuclides from
diagnosis and treatment, 515,000 teletherapy treatments and over 30,000
brachytherapy treatments each YEAR in the United States. The issue is like
shark attacks. We hear of handful and think it is an epidemic. I think the
IOM number of 98,000 needs to be put in perspective, also.
You should also know that the report of misadministration of the wrong
radionuclide to a patient is not a misadministration as the dose to the
organ, the large lower intestines, did not exceed a dose equivalent of 50
rem, and the dose to the dose to the patient did not exceed 5 rem.
-- John
John Jacobus, MS
Certified Health Physicist
3050 Traymore Lane
Bowie, MD 20715-2024
E-mail: jenday1@email.msn.com (H)
-----Original Message-----
From: William V Lipton [mailto:liptonw@DTEENERGY.COM]
Sent: Friday, September 07, 2001 8:00 AM
To: Perrero, Daren
Cc: radsafe@list.vanderbilt.edu
Subject: Re: medical misadventures
. . .
BTW: The problem of medical screwups is not limited to nuclear medicine. I
highly recommend the recent report, "To Err is Human: Building a Safer
Health
System," written by the Institute of Medicine and published by the National
Academy Press, in 2000. According to this report, up to 98,000 persons die
each
year from medical errors in hospitals. Imagine any other industry killing
98,000 persons a year and claiming that they don't need to be regulated!
The opinions expressed are strictly mine.
It's not about dose, it's about trust.
Bill Lipton
liptonw@dteenergy.com
"Perrero, Daren" wrote:
> 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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