Radiation: The Difficulty of Monitoring the Invisible – Post 2 of 2

This post continues the list of articles on HF-related errors in radiation delivering healthcare devices.

As Technology Surges, Radiation Safeguards Lag

But the technology introduces its own risks: it has created new avenues for error in software and operation, and those mistakes can be more difficult to detect. As a result, a single error that becomes embedded in a treatment plan can be repeated in multiple radiation sessions.

A new linear accelerator had been set up incorrectly, and the hospital’s routine checks could not detect the error because they merely confirmed that the output had not changed from the first day.

In another case, an unnamed medical facility told federal officials in 2008 that Philips Healthcare made treatment planning software with an obscure, automatic default setting, causing a patient with tonsil cancer to be mistakenly irradiated 31 times in the optic nerve. “The default occurred without the knowledge of the physician or techs,” the facility said, according to F.D.A. records.

In a statement, Peter Reimer of Philips Healthcare said its software functioned as intended and that operator error caused the mistake.

Radiation Offers New Cures, and Ways to Do Harm

The Times found that while this new technology allows doctors to more accurately attack tumors and reduce certain mistakes, its complexity has created new avenues for error — through software flaws, faulty programming, poor safety procedures or inadequate staffing and training.

X-Rays and Unshielded Infants

Asked about the case, Dr. David Keys, a board member of the American College of Medical Physics, said, “It takes less than 15 seconds to collimate [cover non-scanned portions of the body – AM] a baby,” adding: “It could be that the techs at Downstate were too busy. It could be that they were just sloppy or maybe they forgot their training.”

Other problems, according to Dr. Amodio’s e-mail, included using the wrong setting on a radiological device, which caused some premature babies to be “significantly overirradiated.”

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About Anne McLaughlin

Associate Professor, Department of Psychology, North Carolina State University, Raleigh, NC
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