Misadministrations

["Richard, Mack L" <mrichar@iupui.edu>]

Dear Radsafers:

Boy, do I hesitate to jump into this fray!  What many of those experienced
in medical institutions have said is true - human error is the predominant
cause of misadministrations.  I would also agree that regardless of how
thorough your procedures are, regardless of how much you train, you cannot
totally eliminate misadministrations as long as humans are involved.

Those of you who have been in the medical arena long enough may remember
that initially, a misadminstration was basically defined as any deviation
from what was intended, including diagnostic misadministrations which result
in relatively low doses to patients.  Give the NRC credit, after a while,
they redefined misadministrations to only include events which had the
potential to actually harm the patient (deterministic effects).

Believe it or not, other mistakes happen in hospitals that do not receive
the same degree of scrutiny that misadministrations do.  We've all heard
horror stories where the wrong leg was amputated or a patient had an adverse
reaction to a drug when it was clearly indicated in the patient's chart that
they were allergic to that drug.  When such events happen, is the hospital
required to notify some regulatory agency which in turn investigates and
possibly takes action against the hospital?  Not that I am aware.  But if
the event involves "radiation", suddenly the event becomes a regulatory
issue.  Hmmmmm - wonder why that is (have you been following previous posts
on the radiation "mystique"?).  I'm not necessarily saying this is right,
I'm just saying that's how it is.

The bottom line is that when a patient is actually harmed in an event that
occurs in the hospital, in most cases, the least of that hospital's (and
usually the physician's) worry is a $5000 civil penalty from the NRC along
with the writeup in the newpaper.  The lawsuit filed by the patient (and the
negative publicity associated with same) is probably going to far overshadow
the civil penalty.  The point here is that hospitals and physicians have
more important reasons (both ethical and economic) to avoid
misadministrations.  I've never been thoroughly convinced that the
regulations regarding misadministrations have actually served as much of a
deterrent as the NRC (and the politicians who many times pressure the NRC)
would like to think.  It would be interesting to see if the number of
misadministrations have changed over the course of several years.  Maybe
such information has been published.  If anyone out there is aware of such a
report, I'd be interested.

For those of you unfamiliar with the medical environment, rest assured that
the NRC thoroughly investigates misadministrations.  I've been at IUMC for
over 20 years, so unfortunately I've had the opportunity to observe a few
such investigations first hand.  For those of you fortunate enough not to
have experienced this, my advice is "never say never."

Most physicians I have spoken to feel that the regulations on
misadministrations are an intrusion into the practice of medicine.  The NRC
(or the politicians that influence the NRC) feel that patients are members
of the public and as such, need to be protected under the NRC rules.  I
guess I can see both sides of that issue.  Although I think I know Carol
Marcus' position, it might benefit us all to hear from her - Carol are you
out there?

Regards,

Mack L. Richard, M.S., C.H.P.
Radiation Safety Officer - IUPUI/Indiana Univ. Med. Cntr.
Phone #: (317) 274-0330   Fax #: (317) 274-2332
E-Mail Address:  mrichar@iupui.edu

"Pro is the opposite of Con, so Progress is the opposite of . . ."
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