RE: medical misadministration of I-131

["Sandy Perle" <sandyfl@earthlink.net>]

Most errors, regardless of the industry, are based on human factors. 
It is for that reason the following is sorely needed (again, 
regardless of the industry):

(1) Increased and more pertinent training. This includes refresher 
and competency reviews.

(2) Increased supervisory insight.

(3) Better procedures, and, requiring actual use of the procedures 
(where appropriate). It's the staff with the most years that often 
don't review procedures since they "already know what is required."

(4) Individuals being held accountable for their action, or inaction 
(all levels).

The greater the degree of the human error, especially the seriousness 
of the result, the more analysis needs to be performed. Perhaps more 
use of EMEA should be performed. If it's a system we're addressing, 
perhaps FTA or FMEA should be sought out.

In the case at hand, it is a simple error that should not have 
occurred. This type of mis-administration should never occur. The 
root cause most likely, again, most likely, is an individual, or 
individuals, not paying attention to details. Simple to correct .. if 
management is really interested.


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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