[Date Prev][Date Next][Thread Prev][Thread Next][Date Index][Thread Index]
RE: medical misadventures
In the medical field, physicians are prescribing radiation either to
diagnose or to treat a disease in a human patient. Yet there have been many
instances where something went wrong, and patients have suffered from it. A
misadministration where too little radiation is delivered results either in
the disease/condition worsening, leading possibly to a patient dying, or the
disease/condition recurs. If too much radiation is delivered, the patients
may die, either singly or in groups. Most Nuclear Medicine overdoses have
not been fatal, although some have (e.g., mCi delivered instead of
microcuries). There have also been therapeutic misadministrations,
exemplified by instances in the US (Ohio, 1975), Spain (1990), Costa Rica
(1996) and Panama (2001) where calculational errors occurred and patients
died. There have also been equipment malfunctions, also leading to patient
deaths. There have also been at least two instances in the US where
brachytherapy sources were left inside the patients, resulting in their
eventual deaths, too. For several of the therapy misadministrations, these
were not discovered promptly, and deaths were ascribed to the evolution of
the patients' disease. Needless to say, this doesn't correct the
mistakes...
(this is my opinion only, and does not represent the official policy of my
employer).
J. G. Yusko, CHP
PA Watershed Conference
October 5-6, More Info. at
http://www.pawatersheds.org/2001wsconf
-----Original Message-----
From: carol marcus [mailto:csmarcus@ucla.edu]
Sent: Monday, September 10, 2001 2:21 PM
To: Jack Earley; Vernig, Peter G.; 'Perrero, Daren';
radsafe@list.vanderbilt.edu
Subject: Re: medical misadventures
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
>
>************************************************************************
>This e-mail and any of its attachments may contain Enercon Services, Inc.
>proprietary information, which is privileged, confidential, or subject to
>copyright belonging to Enercon Services, Inc. This e-mail is intended
solely
>for the use of the individual or entity to which it is addressed. If you
>are not the intended recipient of this e-mail, you are hereby notified that
>any dissemination, distribution, copying, or action taken in relation to
the
>contents of and attachments to this e-mail is strictly prohibited and may
be
>unlawful. If you have received this e-mail in error, please notify the
>sender immediately and permanently delete the original and any copy of this
>e-mail and any printout.
>
>************************************************************************
>You are currently subscribed to the Radsafe mailing list. To unsubscribe,
>send an e-mail to Majordomo@list.vanderbilt.edu Put the text "unsubscribe
>radsafe" (no quote marks) in the body of the e-mail, with no subject line.
>
>
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>
************************************************************************
You are currently subscribed to the Radsafe mailing list. To unsubscribe,
send an e-mail to Majordomo@list.vanderbilt.edu Put the text "unsubscribe
radsafe" (no quote marks) in the body of the e-mail, with no subject line.
************************************************************************
You are currently subscribed to the Radsafe mailing list. To unsubscribe,
send an e-mail to Majordomo@list.vanderbilt.edu Put the text "unsubscribe
radsafe" (no quote marks) in the body of the e-mail, with no subject line.