This week’s NY Times tells the heartwrenching tale of two patients who suffered radiation injuries during treatment for cancer. In one case, a 43 year old man being treated for tongue cancer recieved seven times the prescribed radiation – a lethal dose – to the head and neck. A woman recieved three times the recommended radiation dose to her breast, leading to a chronic festering wound that took over a year to heal – she ultimately died of her cancer. In both cases, there were multiple missed opportunities to identify the computer error and prevent the injury.
I encourage you to read this excellent article which explores both the hope and the risks of radiation therapy.
Stories like these cry out for a technological solution – a failsafe mechanism on the expensive and complicated equipment used to target and deliver radiation to treat cancerous tumors.
And yet, I found myself wondering if a simple checklist might have worked just as well.
We already use checklists when giving chemotherapy, with each dose being checked by two individuals prior to its administration.
We need a similar nationwide standard for radiation therapy.
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Orac does a thoughtful analysis of the article, including a call for checklists. THe discussion in the comments section is well worth reading
In most cases it is not the technology that needs a failsafe. The technology must allow the clinicians to perform a task. However, it is up to the clinicians to ensure that it's the right task. In most cases of mistreatment you'll find that clinic staff have failed to do proper QA per TG-40. See http://www-naweb.iaea.org/nahu/dmrp/pdf_files/Chapter12.pdf or AAPM for further info. I concur, a simple QA checklist seems like a good idea, but it's something that every clinic should be doing per standard practice. If they're not, they're not following the standardized practices.
Anonymous – thanks so much for this comment and the link.
It's one thing to have standards, another to mandate them.
Are these standards mandated, or just recommended?
Margaret..I write and edit the online member newsletter/blog for RASMAS, the nonprofit recall tracking service. We compile recall and safety alerts, in checklist form, for hospitals and healthcare facilities to make sure all the problems with radiation machines are addressed. In addition, our members share tips and information to make the machines work better. I am working on gathering some info on this topic so will email you when I get the stats from staff.
These sorts of articles scare the dickens out of me. There's no way to protect oneself from these sorts of errors, especially if one's already ill. And there's no way to make the person "whole" in any way.
Scary.
thanks for the info.. nice article.
A simple checklist is also something that can reduce infections when practitioners follow infection control steps.
The same with time-outs. I recently had shoulder surgery. Timeouts were called every step of the way to verify my identity, the body part and the procedure being done. I was impressed and felt safer.
But they are not universal. I don't understand why. Who doesn't want the best for their patients?!