Re: Breast-cancer patient gets radiation overdose -Reply-Reply

[Kathleen Kaufman <KKAUFMAN@dhs.co.la.ca.us>]

According to the email message, this facility was not doing treatment
verification- they now plan to do so! There are many facilities that do not.
Perhaps the dreaded Radsafe word- regulations!!- need to require one or
more of these steps. I am POSITIVE that if regulations don't require some
of these procedures, there will be facilities that won't do them. I'm
specifically thinking of some stand-alone facilities, but the Univ of WA
obviously doesn't fall into that category.
kkaufman@dhs.co.la.ca.us



>>> "Sandy Perle" <sandyfl@earthlink.net> 12/08/98 02:43pm >>>
> The American College of Radiology has written Standards of Practice
for
> linear accelerators. They state that the medical physicist should review
> the patient's records at least once a week. That doesn't mean that the
> physicist would actually observe a treatment. Unless the unit provides
a
> record (record & verify) of the treatment (it's my understanding that
> some newer units do this), I suspect that the physicist wouldn't have
> been able to find this error (it appears that the tech hadn't entered the
> use of a wedge into the treatment plan) by looking @ patient charts. If I
> needed rad therapy I'd ask if they used a dose verification system on
the
> first treatment.

The verification I referred to is the information regarding the:

1. Dose to be applied to the patient per treatment
2. Verification by 2 individuals regarding the settings put in by the    
    technicain (or whomever set up the unit for the irradiation)

The statement above that "I suspect that the physicist wouldn't have
 been able to find this error (it appears that the tech hadn't entered the 
use of a wedge into the treatment plan) by looking @ patient charts" can
not 
be acceptable. Someone is accountable. There must be a process 
to preclude these mishaps from happening. They don't always 
happen, so somebody must be doing something right.

This issue included 20 treatments over a 1 month period. There is 
something seriously wrong with the way this facility runs their 
program (in this instance anyway).


Sandy Perle
E-Mail: sandyfl@earthlink.net 
Personal Website: http://www.geocities.com/capecanaveral/1205

"The object of opening the mind, as of opening 
the mouth, is to close it again on something solid"
              - G. K. Chesterton -
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