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Re: medical misadventures
William,
IMHO, I think you are reading more into Daren's statements than he may
intend. If you are talking about therapy procedures, then your
statements have some validity. But I believe Daren is refering
primarily to diagnostic procedures, which are the large majority of
nuclear medicine procedures. That I know of, there is no evidence to
indicate that any harm is being done to the patient in such procedures.
I very seriously doubt that any patient has ever died from recieving the
wrong diagnostic dose, or the wrong diagnostic radionuclide. I would
guess that you are more likely to die from a freak needle stick
accident.
I agree that even diagnostic misadministrations must have
review/correction/improvement. It should be something like "repeat
analysis" for x-ray departments, though. But it should NOT be blown out
of proportion in such a way as to needlessly alarm the patient. For
therapy situations, you are quite right to be concerned, because people
have died from therapy misadministrations. I don't think its anywhere
near 98,000 though :) I am pretty familiar with the medical regulations
for radiation, and they are not insufficient in the area of
misadministrations.
There may be a need for more "review" of misadministrations. But the
medical situation is very different from the reactor situation. In a
nuclear medicine department, there is a relatively limited number of
things that can go wrong, and we can predict what the consequences will
be for a given event. At the reactor, you have an incredibly complex
system which can behave unpredictably if an unexpected event or
combination of events occurs. When someone at some reactor determines
that X event produces Y undesireable consequece, its natural and
neccessary that everybody takes note to make sure that X event never
happens at their reactor. What I am saying is that we should not go to
far in trying to make nuclear medicine departments run like reactors.
Just My Opinion
_______________________________________________
Gary Isenhower
713-798-8353
garyi@bcm.tmc.edu
William V Lipton wrote:
>
> I have a major problem with your response, especially since you seem to be a
> regulator. I am especially concerned by your apparent belief that no harm is
> done for either underdosing or overdosing. In the first place, many of these
> events involve the wrong radionuclide, wrong patient or wrong injection site.
> That argument obviously doesn't apply to those cases. I thought that part of a
> physician's ethical obligation is to, "Above all, do no harm." Secondly, I
> can't buy that the dose being off spec is unimportant. Physicians have an
> obligation to administer the minimum dose required to provide the needed
> diagnosis or therapy. (A reasaonble margin of safety is allowed.) If less dose
> is administered, then the therapy is not effective. If more dose is
> administered, then there's unnecessary radiation exposure.
>
> The high incidence of medical screwups and the apparent attitude of many in the
> medical community that it's "no big deal" indicates the need for more aggressive
> regulation by the NRC or Agreement States.
>
> 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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