ANECDOTES ON RADIATION RELATED INCIDENTS

[JOHN CAMERON <jrcamero@facstaff.wisc.edu>]

Dear Colleagues:
	From time to time accidents happen or errors occur involving
medical use of radiation or radiation-related devices. Some of these have
serious or even fatal consequences. Others have minor repercussions but
they might have been serious under other circumstances. Many others are not
serious but represent poor practice.  Some accidents, such as the Therac-25
incident, are thoroughly documented in the archival literature.  Many other
medically related radiation "accidents" or "incidents" never become known
to the radiation community. Often they are settled "out of court." Often
the facts are not disclosed because they are under litigation for many
years. Many of these incidents involve medical physicists, directly or
indirectly.  We feel there is a need for a compendium of authoritative
accounts of such incidents so that the radiation community can be made
aware of these "errors" in judgement, equipment, practice, communication,
or what ever so that we may learn from them.
	 If you have reliable information about a radiation "accident" or
"incident" that you can describe in enough detail to make clear the cause
of the problem, we would welcome a short, clear description of the
accident, including its repercussions. We suggest the following general
outline: type of accident, how it happened, injuries or potential late
injuries, actions taken (if any) to reduce similar accidents, legal
repercussions (if any) and a brief commentary.
	Even if you are involved with the incident, it should be written in
the third person. We do not wish to publish any information that would
identify the individual(s),the date or location of the incident, except to
the extent that such information is important to understanding some aspect
of the incident and is not compromising to anyone involved. The purpose is
not to cause embarrassment but to inform and educate. You may add a SHORT
commentary on the moral to be learned or the ethical issue involved. If a
description of the incident has been published, it would be useful to give
the reference, if it is known. (Even if the description includes errors.)
	We, of course, reserve the editors' right to provide meta-analysis
and commentary. "Radiation" includes all forms of ionizing radiation as
well as the entire electromagnetic spectrum (UV, IR, etc.). Incidents could
also include electrical and mechanical risks from radiation related
equipment. (See examples below.)
	If an accident involves radiation equipment but the hazard was not
from radiation, it might still be an acceptable anecdote. For example, many
years ago at the U. of Wisconsin we had two such accidents. In one case the
plastic window on a hyperbaric oxygen chamber with three atmospheres
(gauge) of O2 ruptured. Several staff were hospitalized and the patient had
bilateral collapsed lungs but there were no direct deaths.  The other case
involved a rectalinear nuclear medicine scanner. The mechanical support of
the detector and its heavy lead shielding "let go" and about 250 kg fell on
the patient's head, contributing to her death. Both of these incidents were
reported at the time to proper authorities but we doubt if they ever
reached the general medical physics community. Both accidents involved
errors in design of the equipment.
	When we distribute the compendium of these accident cases, by means
yet to be determined,  the contributors names will be listed in
alphabetical order in the acknowledgements (unless they do not want to be
listed at all). That is, contributors will not be identified in connection
with any particular incident.  It is uncertain at this time how the
compendium will be distributed - perhaps in Medical Physics or Health
Physics and on the Internet.
	 We would appreciate your contributions and your suggestions. Items
may be sent to either (or both) of us by e-mail or by other means. We would
rather not have third hand stories.  However, if you think nobody else
might report them pass them along.  Please let us know so they can be
treated with the proper scepticism. (They might still be included but with
a note that some of the facts may not be correct.)
	We await your contributions. Feel free to contact either of us by
e-mail if you have a question. We hope to have enough useful anecdotes by
the end of this year to make them available to the medical physics and the
general radiation community. Best wishes, John & George

John Cameron (jrcamero@facstaff.wisc.edu)
P.O. Box 405, Lone Rock WI 53556  Phones: 608/583-2160; fax: 608/583-2269
[until 9/25/97]
[after use:] 2678 SW 14th Dr., Gainesville, FL 32608 Phones: 352/371-9865;
fax 352/371-9866

George Sherouse (sherouse@RadOnc.MUSC.EDU) Med. Univ. of S. Carolina, Rad
Oncolgy Dept 171 Ashley Ave. Charleston, SC 29425-0721; Phone:
803/792-3271; fax 803/792-5498.