RE: medical misadministrations

[Glen.Vickers@ucm.com]

Group,

I'm not sure the root causes of many of these mis-adminstration incidents
has much at all to do with health physics, but more with human error.  Most
of the incidents I've heard of could have been prevented by actions such as
self-checking, independent verification, concurrent verification, three-way
communication, clarifying and confirming communications, etc.

Contact your local nuclear power plant for error prevention methods you can
use in your daily life.  Everyone feels they are understaffed, but I feel
the level of self-checking or error detection you use is proportional to how
much you care.  It is far better to spend a couple of extra minutes a day on
error prevention, than to attempt to explain your error to a regulator or a
parent whose infant child is a victim of your inappropriate action.

Most Sincerely,
Glen Vickers
glen.vickers@ucm.com




	-----Original Message-----
	From:	William V Lipton [SMTP:liptonw@dteenergy.com]
	Sent:	Friday, August 27, 1999 12:36 PM
	To:	Multiple recipients of list
	Subject:	medical misadministrations

	I received the attached response to my original posting by private
	e-mail, and am posting it to RADSAFE with the author's permission.
I
	removed the author's name at her/his request.  Although I don't
agree
	with all of it, I think that this response provides a lot of insight
	into the recent "epidemic" of misadministrations.

	The opinions expressed are strictly mine.
	It's not about dose, it's about trust.

	Bill Lipton
	liptonw@dteenergy.com


	 Bill,
	>
	> In response to your e-mail this morning regarding another medical
	> misadministration, I would like to say that you are probably
	preaching to
	> the wrong people.  I do not know your background, but I do know
that
	you
	> currently or at one time worked at a NPP.  I also do not know if
you
	are
	> familiar with 10 CFR Part 35 "Medical Use of Byproduct Material."
	>
	> I agree with you that the rates of these types of events are to
high.
	The
	> reason I think is simple.  Most nuclear medicine programs across
the
	country
	> do not have a "professional" HP on staff.  (The exception would be
	most
	> teaching hospitals with research.)  The reason for this is found
in
	35.900
	> that addresses the training and experience for RSO's in medical
	facilities.
	> This section allows almost any "certified" physician (35.900(a))
and
	any
	> authorized user (35.900(c)) to be an RSO, regardless of training
	and/or
	> experience.  I would suggest that you do a survey of the hospitals
in
	your
	> area, including hospitals of all sizes and find out how many
actually
	have
	a
	> "professional" HP as RSO.  I think that you would be surprised.
	> Unfortunately the NRC needs to have this rule since there are not
	enough
	HPs
	> to go around.  I which I think you know.  In the revised rules
that
	were
	> recently sent to the NRC commissioners they proposed a small step
in
	the
	> right direction, a very small step. Authorized users that wish to
	become
	> RSOs will need "experience with the radiation safety aspects of
	similar
	> types of use."
	>
	> It is my impression that you, and many other "professional" HPs on
	RADSAFE,
	> would not think that I am qualified to be a "professional" HP.  I
	qualified
	> to be a RSO by fulfilling the requirements of 35.900(b).  I have a
	4-year
	> physics degree and my initial experience under a very competent
HP,
	who is
	> now a CHP.  I am also in the initial stages of pursuing
certification
	at
	> this time.
	>
	> Another problem for "professional" HPs in medical facilities is
	staffing.
	> The NRC does not or can not dictate staffing levels. (I am not
sure
	if
	they
	> can at NPP either.)  Back in 1986, after a NRC inspection (before
I
	was
	> here), the inspection report stated that the NRC thought that the
	staffing
	> at this facility was not adequate.  The director of the facility
sent
	a
	> letter back basically stating that the NRC cannot determine for
him
	what
	the
	> staffing levels should be.  (I have a copy of the letter if you
would
	like
	> to see it.)  The NRC stopped pushing the issue at that time and
there
	is
	> still only one HP at this facility.
	>
	> If you really think that this is a big problem I encourage you to
	petition
	> the NRC with a rulemaking on the issue of qualifications for RSOs.
I
	am
	> sure that you would have the support of many HPs, including
myself.
	>
	> I once went to a talk and the main thing that I come out with was
"No
	> problems, without solutions."  It is hard to do.  I find myself
	failing at
	> it all the time.  What is the solution to this one?  I don't know
	yet.
	But
	> the comments in your e-mail don't help.  What are your
"solutions"?
	>
	> Thanks for your time.
	>

	
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