Breast-cancer patient gets radiation overdose

["Pickett, Bruce D" <Bruce.Pickett@PSS.Boeing.com>]

The following article appeared in the December 5, 1998 edition of the
Seattle Times newspaper. It is also available on their web site at this URL:
http://www.seattletimes.com/news/local/html98/radi_120598.html

Bruce Pickett
bruce.d.pickett@boeing.com

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Copyright © 1998 The Seattle Times Company

Posted Saturday, December 5, 1998

Breast-cancer patient gets radiation overdose at UW
by Warren King Seattle Times medical reporter

A breast-cancer patient at the University of Washington Medical Center may
need surgery after errors by hospital personnel caused her to receive more
than twice the prescribed radiation during the past month.

The woman, described only as in her early 40s, may need plastic surgery or a
mastectomy as a result of the overdose. The possible damage - hardening and
shrinking of the breast and skin deterioration - won't be apparent for at
least nine months, said Dr. George Laramore, acting director of the UW
Cancer Center.

It was the second such incident at the UW in the past 5 1/2 years. A boy
about age 10 suffered hearing loss after a radiation overdose during
successful treatment of a brain tumor in 1994, UW officials said.

State and federal health officials and physicians said such accidents are
very rare. A veteran official said that except for the boy, the recent case
is the first known serious radiation treatment overdose in the state in
nearly 12 years.

"Everyone involved obviously feels terrible about it," said Laramore. "We're
trying to understand at what levels in treatment there may be problems and
make sure it doesn't happen again."

In 1996, an attorney for the boy contacted the medical center, but there has
been no legal action, and negotiations for a damage settlement are not in
progress, a UW spokesman said. The breast-cancer patient also has taken no
action, Laramore said.

The most recent radiation accident was discovered when the woman's skin
turned red, like a sunburn, Laramore said. The woman received a total of
about 7,600 rads of radiation over the four weeks instead of the prescribed
3,600 rads.

There is about a 50 percent chance the patient will develop the problems
requiring breast surgery, Laramore said. There is also a risk that she will
have rib fractures and chronic pain and a slightly increased long-term risk
she will develop a radiation-associated cancer from the overdose.

State officials said they are satisfied with measures the UW is instituting
to prevent any more such accidents.

Laramore said the overdose occurred because a radiation filter inadvertently
was omitted from the treatment machine, called a linear accelerator. The
wedge-shaped filter is designed to tailor the amount of radiation delivered
to different portions of the breast and chest.

Two errors allowed the overdose, Laramore said. A technician incorrectly
entered the prescribed radiation dose into the linear accelerator's
computer. Then a medical physicist failed to catch the error during any of
four weekly medical record checks.

The system of weekly record checks was instituted after the accident
involving the boy occurred in 1994. Laramore said the physicist is still
employed at the UW while the department of radiation oncology investigates
the accident.

"We don't like to make the same mistake four weeks in a row," said Laramore,
obviously upset by the error.

Dr. Eric Larson, medical director of UW Medical Center, said: "We've really
got to do all we can to design fail-safe systems to make sure this doesn't
happen again. I was really devastated, quite frankly, when this second
incident happened."

Mike Odlaug, director of the X-ray control section of the State Department
of Health, said he remembers only two other accidents as serious as the UW's
during the past 20 years. Both occurred at Yakima Valley Memorial Hospital
but involved an equipment software problem, not human error.

In January 1987, a 60-year-old man received an overdose of radiation while
undergoing treatment for a chest tumor. He died of respiratory failure about
three months later. Doctors said radiation was a contributing factor.

About a year earlier a woman also had received a radiation overdose and
later developed problems with her hip, Odlaug said. Hospital officials later
said they suspected the overdose stemmed from the same software problem.
Odlaug said the machine is no longer used by most hospitals, including the
UW.

Linear-accelerator accidents that involve equipment malfunction or cause a
death must be reported to state officials. Other incidents don't have to be
reported except in certain circumstances.

"There are probably many incidents of much more minor consequence (than the
UW accident) that are quickly discovered and remedied and not reported,"
said Odlaug. "What is unusual about this recent incident is that it went
uncorrected for 20 treatments."

A spokesman for the American College of Radiology said patients receive
about 20 million radiation treatments a year in the U.S., most of them with
linear accelerators. The incidence of errors causing significant damage to
patients is extremely low, said Michael Bernstein, public-information
officer for the speciality association.

Laramore said he believes there are many more significant errors than
officials think.

"People just don't talk about it," he said.

The UW Cancer Center gives radiation treatments to about 1,000 patients a
year, Laramore said. Two significant accidents in 5 1/2 years is not such a
bad record, he said. Because the center also uses the most modern technology
and "pushes the envelope" to get the best results, there is a higher risk
for errors, he said.

"When everything works right, I think the patient gets the best treatment
possible here," said Laramore.

Laramore said the center is taking several fail-safe measures to prevent
future accidents:

After one technologist enters the prescribed treatment parameters in the
linear accelerator, another technologist will immediately check the screen
to ensure the entry is correct.

After the first week of treatment, one physicist will check the patient
record to ensure the prescribed treatment has been given. After the second
week, a different physicist will check the record.

On the first day of treatment, the patient will wear a device to measure the
precise amount of radiation actually being administered.

Center officials will seek software changes in the system to reduce the
chances of human error.

Laramore said he believes the linear-accelerator manufacturer also should
alter the machine's design so its computer screen will give clear warnings
when a wedge radiation filter is not in place. Unlike older model machines,
the filter is concealed inside the machine.

A spokesman for Elekta Instruments, maker of the machine, said the company
had no comment.

Copyright © 1998 The Seattle Times Company

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