Radiation Errors

Summary:

Reflections on radiation errors

Radiation Errors

Santam Chakraborty 02 Mar 2010 17:14

Another new article has come up in which inadvertent overdose of 76 patients due to SRS. Apparently it was due to the fact the chief physicist choosing a wrong chamber (??). News articles state the BrainLab representative was present during the calibration process. Now that the physicist no longer works there and can't defend himself is this a case of blame shifting?

1. What are the thoughts of the house on this incident?
2. Do you feel physicist are under pressure by the management to perform specially in private centers (I have heard personally from a physicist in a recently opened private centre how much pressure he was under to ratify a wrong building plan in order to save money.)?
3. Do you feel an external audit should be made mandatory during installation and commissioning of a new equipments?
4. Do you feel vendors are interested in selling and not in post selling machine upkeep?

Here is the link for the story
http://www.ky3.com/news/local/85241082.html

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Last edited on 02 Mar 2010 17:20 by Santam Chakraborty Show more

Re: Radiation Errors

HM 06 Mar 2010 15:10

The Indian context is really not very different.I believe this kind of thing is often swept under the carpet especially in brain mets(as I understand the above article to refer to).However I believe AERB does carry out an audit which is voluntary and helps provide reconfirmation of at least basic output data for the machine.The annual returns also are quite voluminous and contain details of the phantoms and other QA tools used .It would have to be a very foolhardy physicist/RO combination indeed to attempt to fudge these data.

Re: Radiation Errors

Nikhilesh Patil 06 Mar 2010 17:22

Dear Santam, Iam doing a course on Ethics and Errors and last week there was talks on IAEA reported 5 incidents. Remind you these are the 5 which were reported and there are several which is not. I have also heard of similar stories that you told however Iam not aware of any mechanism to stop such practice.
http://rpop.iaea.org/RPOP/RPoP/Content/InformationFor/HealthProfessionals/3_NuclearMedicine/TherapeuticNuclearMedicine/TNM_AccIncidents.htm
It is the responsibility of the whole team to make sure that the treatment units are safe enough to use for patients.

Re: Radiation Errors

AAM 10 Mar 2010 00:45

you can't "stop this practice" as it is not something that anyone sets out to stuff up (hopefully not!).

the processes are complex and people are people, they are lazy, uninterested, untrained, pre-occupied, feel sickly, episodically distracted, etc. You can pick any or all of these!

we take these reports and ask our physics staff - " can tell me how this hasn't been and can't happen here? And can you tell me why you can be so sure?"

That's all you can do.

Re: Radiation Errors

Nikhilesh Patil 10 Mar 2010 00:52

Hi Andrew, I agree with what you are saying, errors are bound to happen however we should all learn from these errors and try and make our individual radiation centres safe for everyone. People should report there incidents so as to prevent others from committing similar mistakes.

Last edited on 10 Mar 2010 00:52 by Nikhilesh Patil Show more

Re: Radiation Errors

Nikhilesh Patil 10 Mar 2010 00:23

http://www.clin.radfys.lu.se/ This is the place where you can report, There are many other systems which are under progress for Radiation Incident Reporting. Following the ASTRO announcement we cant turn a blind eye towards all this.