Re: Radiological overexposure

["Sandy Perle" <sandyfl@earthlink.net>]

Thank you J.J. for providing that excellent summary. It points out a 
few key elements that would have prevented this occurrence in the 
first place:

1. The calibration performed by whomever was in error.

2. There was NO VERIFICATION performed that verified the initial 
calibration. If this were done, the error would have been identified 
and corrected.

3. No ongoing Quality Assurance Program in place to determine 
the effectiveness of the equipment condition, and, radiation output.

4. ALL individuals who have an accountability in the calibration, 
verification and ongoing oversight are at fault. The fact that there 
was no "apparent" oversight perhaps hypothesizes that there was a 
lack of procedural control, either by individuals governed by written 
documentation.

This incidence, though rare (perhaps) points out the need for 
ongoing training, procedures and an effective QA program. I'd 
venture to guess that there was no verification due to the fact that 
the individual who performed the calibration KNEW the process 
(having done it many times before), the physician didn't need to 
check anything (having done it many times before), etc. This is 
complacency. It is an evil that affects many other industries as 
well.. Knowing what to do should not eliminate the checks and 
balances. An ongoing QA program with ongoing verifications is a 
requirement. Lives are dependent on it.


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