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RE: medical misadministrations
You are "right-on". I have investigated a dozen or more of these
incidents over the years and almost without exception the person
assumed in place of verifying a critical part of the administration
procedure protocol.
--- Glen.Vickers@ucm.com wrote:
> 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
>
=== message truncated ===
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