RE: medical misadventures

["Feldman, Gerald" <gfeldman@MSX.NDC.MC.UCI.EDU>]

Gary,



There are indeed diagnostic NM procedures that can cause death or serious

injury.  Any procedures that involve labeling of blood or blood products

with subsequent re-injection of the material back into the patient can be

extremely dangerous if the blood from one patient is injected into another

(wrong) patient.  This can cause graft vs. host disease or can lead to the

transmission of diseases such as hepatitis or AIDS.  Because this type of

error is so serious, hospitals should have multiple layers of procedures in

place to prevent them.  Of course, the risk of harm here is NOT from

radiation. 

 

Gerald Feldman, M.S.

Radiation Safety Officer

UCI Medical Center

Orange, CA

gfeldman@uci.edu





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

From: Gary Isenhower

To: William V Lipton

Cc: Perrero, Daren; radsafe@list.vanderbilt.edu

Sent: 9/7/2001 2:03 AM

Subject: 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



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