Radiation Accidents

["Roy A. Parker" <70472.711@CompuServe.COM>]

Michael,
 
You most  certainly want  the most  infamous of  the medical  incidents.
Indiana, Pennsylvania.   High  Dose Remote  Afterloader.    Source  wire
retracted.   Source position  indicator light said source was in storage
position.  Area monitor in room was alarming.  Area monitor ignored.  No
survey performed.  Source left in patient.  Patient died.  NRC files are
replete with this incident.
 
Non-radiation incident;  but radiation  therapy machine  incident.   Way
back in  early 70's,  Lake Charles,  Louisiana.   Theratron 80.    Relay
stuck.  I forget, but either table continued to rise or arm continued to
rotate.  Either way, result was patient's chest crushed.  Patient died.
 
Roy A. Parker, Ph.D.
E-Mail: 70472.711@compuserve.com
Tel: 504-924-1473
Fax: 504-924-4269
Pager: 800-759-7243 PIN 30630
-------------( Forwarded computer archived letter follows )-------------
    21-May-97 22:08 CDT
Sb: Radiation Accidents
Fm: Michael Gazda > INTERNET:gazda@worldnet.att.net
 
 
Hopefully I can get some help from my fellow MedPhysicists.  I am
planning on giving an informal 1 hour talk to our staff (clinical and
clerical) on radiation accidents.  What I want to discuss is (1) those
incidents where a machine or staff problem caused patient injury in a
rad therapy dept and (2) those concerning injuries caused by public
exposure to radioactive materials in general.
 
I do have info on the Therac-25 problem, the Brazilian family with the
Cesium source and the cobalt decay problem that overdosed patients, but
that's it. I would think that there must be a compilation of these
accidents out there somewhere, but I can't locate it.  I've searched the
net, nrc.gov and amazon.com (book titles), but to no avail.
 
I don't plan on making this a morbid presentation, just one that
demonstrates the potential dangers involved when working in our field.
Any help on where I can get this info would be greatly appreciated.
 
The areas I plan on discussing are:
 
        HDR
        LDR
        Linac accidents
        Cobalt accidents
        Injuries caused by lost (and eventually found by the unfortunate
individual) sources
 
This might be of some interest to the subscribers of this listserver, so
any replies can certainly be posted here.  If you want to email me, my
address is...
 
gazda@worldnet.att.net
 
Thanks.
 
Michael Gazda
Medical Physicist
Temple University Cancer Center
Philadelphia (Flyers!!), PA