Re: medical misadventures

[carol marcus <csmarcus@ucla.edu>]

At 10:26 AM 9/10/01 -0500, Jack Earley wrote:

>>Another difference between power plant health physics and NM HP is that

>> radioactive materials and radiation is deliberately applied to humans in

>NM

>> which is not the case in power plants.  When there is a monumental

>mistake,

>> or rather series of mistakes, you get a Three Mile Island.  In NM when

>there

>> is a big enough mistake in therapeutic use you get a death.  These have

>been

>> relatively rare.

>

>Good point, here. There were no deaths from TMI.

>

>Jack Earley

>Radiological Engineer

>

>Enercon Services, Inc.

>6525 N. Meridian, Suite 503

>OKC, OK  73116

>phone: 405-722-7693

>fax:       405-722-7694

>jearley@enercon.com

>

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Dear Radsafers:



I think that the statement that radiation deaths from nuclear medicine

mistakes are "relatively rare" is somewhat misleading.  In the entire

history of nuclear medicine, beginning in 1936, there has been ONE probable

radiation death due to a nuclear medicine mistake.  This occurred with an

administration of Au-198 colloid for a liver scan, in which millicuries were

administered instead of microcuries.  The patient died of liver failure, but

had underlying liver disease as well. This occurred, I believe, in the

1950's.  On the other hand, there have been, very roughly, about 350,000,000

administrations of radiopharmaceuticals to patients from 1936 to the

present.  That's not a bad track record.



There is no regulation to prevent this even now.  It was human error.  We

have had a few of these "micro-milli" mistakes, but none of the others have

killed anyone.  The only thing that minimizes human error is (1) solid

education of those involved in the practice (physicians, technologists,

nuclear pharmacists), and (2) having adequate resources with which to

practice the profession carefully (something very difficult to do with

today's low reimbursement rates and the high costs of compliance with

meaningless paperwork that is called "radiation protection" but actually

only provides paper for inspectors to inspect).  



Current NRC and Agreement State requirements for education of Authorized

Users are pathetic, and appear to be optimized for User Fee collection, not

the assurance of competence.  Only about half the States require nuclear

medicine technologists to be certified.  Nuclear pharmacist education is

actually rather good, fortunately.  The "new" Part 35, if it ever goes

through, will cost about a billion dollars the first year, including

licensing requirements that now, for the first time, have achieved the

status of de facto regulation.  



It would seem that the regulators themselves are doing everything possible

to subvert the two factors that DECREASE human error.  Why do you suppose

that is?



Ciao, Carol



Carol S. Marcus, Ph.D., M.D.

Prof. of Radiological Sciences and of Radiation Oncology, UCLA

<csmarcus@ucla.edu>



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