Re: Radiological overexposure

[rkathren@tricity.wsu.edu (Ron L. Kathren)]

Just out of curiosity, didn't anyone bother to empirically verify the
calculations?  If not, I would suggest a bit of malpractice!

Ron Kathren

At 09:59 AM 8/2/98 -0500, Sandy Perle wrote:
>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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