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

Re: Radioisotope misadministrations



The report of the US Nuclear Regulatory Commissionon 
radioisotope misadministrations in FY1996 actually totaled 
13 occurrences in brachytherapy and 7 in nuclear medicine.  
I strongly suspect that these are the result of human 
error, although use of inadequately trained personnel could 
have been a factor.  Such accidents are intolerable and all 
efforts must be made to eliminate them.
It is informative to put these data in context.  It has 
been estimated that some 7.5 million nuclear medicine 
procedures and about 700,000 brachytherapy procedures are 
performed per year in the US.  Thus the misadministration 
rate (order of magnitude)is about one per million for 
nuclear medicine and ten per million for brachytherapy.  
These are "small number statistics" and I suspect that 
there is no significant difference between these two rates. 
I further suspect that these rates are probably lower than 
those for misadministration of medicine, either from error 
in prescribing by the physician or error in providing the 
prescribed medication by the pharmacist.
All possible effort should be made to eliminate these 
errors.  However, it is unlikely that human perfection can 
ever be achieved.  We readily accept imperfection in most 
human activities--but not medicine.
***********************************************************
S. Julian Gibbs, DDS, PhD               Voice: 615-322-3190
Professor of Radiology                    FAX: 615-322-3764 
Dept. of Radiology & Radiological Sciences
Vanderbilt University Medical Center
Nashville TN 37232-2670 Email:s.julian.gibbs@vanderbilt.edu
***********************************************************
If it's free, it's advice;
If you pay for it, it's counseling;
If you can use either one, it's a miracle!

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