[Date Prev][Date Next][Thread Prev][Thread Next][Date Index][Thread Index]

Here's what happens when you don't know which end is up!



[from NRC events report for March 31, 1999] 
 
A MAN SCHEDULED FOR A THERAPY DOSE TO HIS COLON WAS GIVEN A BRAIN TREATMENT 
| 
| INSTEAD.                                                                  
  
| 
|                                                                           
  
| 
| The text following information is a portion of a facsimile received from
the 
| 
| Tennessee Department of Environmental and Conversation Division of        
  
| 
| Radiological Health:                                                      
  
| 
|                                                                           
  
| 
| "On 03/30/99, the Radiation Safety Officer at Methodist Central Hospital, 
  
| 
| Memphis, reported a therapeutic misadministration to the Memphis Field    
  
| 
| Office Manager.  The event occurred on 03/29/99.  A man scheduled for a   
  
| 
| therapy dose to his colon was given a brain treatment instead.  The dose
to  
| 
| the brain was 200 rad.  The man answered to the wrong name when called for
  
| 
| treatment.  A written report will be submitted to the State of Tennessee  
  
| 
| Department of Environmental  and Conservation  Division of Radiological   
  
| 
| Health within 15 days."                                                   
  
| 
|                                                                           
  
| 
| The machine used was a linear accelerator.                                
  
| 
+------------------------------------------------------------------------------
+ 
 
The opinions expressed are strictly mine. 
It's not about dose, it's about trust. 
 
Bill Lipton 
liptonw@dteenergy.com 

************************************************************************
The RADSAFE Frequently Asked Questions list, archives and subscription
information can be accessed at http://www.ehs.uiuc.edu/~rad/radsafe.html