[NEW YORK TIMES, RADIATION ERRORS]

New York Times Radiation Errors

Vincent M. Lucas
Student Argosy University

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Scott Jerome-Parks and Alexandria Jn-Charles were both victims of

radiation treatment incidents that could have been avoided. As reported by
the New York Times, there were 621 treatment errors reported at the time
that the article was released. For various reasons many in the health care
community believe incidents are under reported. However, the two most
common statistical errors are, one, the irradiation of incorrect locations which
results in under & overdosing of the intended target to missing the target all
together. And second, the absence of or incorrect use of beam shaping
devices; leading to un-needed exposures to the patient. The frustrations of
the Radiation Therapeutic community justified in the belief that most if not
all of these incidents could have been prevented by following safety and
quality assurance policies that are in place to prevent such occurrences.
There were also software & technical issues that are addressed as well. In
Scotts case although it was a software issue the complacency of the
therapist and failure to check and verify the treatment plan that called for
the use of MLCs resulted in an enlarged treatment field. This treatment field
led to the exposing of critical structures to radiation. With Alexandria, human
error resulted in the absence of a positioning device; the lack of attention to
detail by the therapist led to over exposure on twenty seven separate
occasions.
Common injuries resulting from these oversights are tumor growth
when the under-dosing occurs at the target site and with over-dosing, the

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end product would result in necrotic wounds, scarring of the skin surface,
burning of the skin, and in the most severe cases organ failure. To counter
act the effects of such irradiation it is necessary to assist the body to
regenerate and hopefully repair damage. The most common treatment used
to facilitate such repair is the use of a hyperbaric chamber. The use of such a
tool allows the patient to receive elevated amounts of oxygen into the blood
giving nourishment to injured tissue, bone, and organs, promoting
regeneration and repair at the cellular level.
In both of the stated incidents injury to organs were documented.
Although Scott was only recorded to have had only three mistreats he
suffered trauma to the brain stem and larynx. Immediately the acute effects
of the overdose caused swelling, inflammation of the face and neck, and skin
burns resulting in difficulty swallowing. Also in addition the chronic effects
Scott endured included ulcers of the mouth, severe burns, deafness, partial
blindness, and stricture leaving him struggling to breath. Alexandria,
however, due to the over irradiation of the breast tissue compromised the
chest wall, muscle, bone, and parts of the lung. The acute effects began with
irritation and slight burn of skin. These effects progressed into a chronic
effect of a wound that continued to grow, perforating the skin, muscle and
the chest wall.
Under reporting of such incidents are a common occurrence due to
many factors. Accidents that go unreported are in part due to under staffing

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and training in addition to software, technical, and charting errors. The state
of New York protects the identity of the facilities and the number of
occurrences of radiation errors in the hopes that this policy will not
discourage those seeking cancer treatments. I do agree with their motives in
this regard, however I am puzzled as to why such under reporting takes
place. One would assume that with this policy in place that reporting
accidents at the facility level wouldnt be an issue. I would assume that
reluctance on the individual therapists part is the biggest factor reporting
such accidents. Although the majority of these accidents do not violate New
York state law I assume the therapists in question would be exposed to some
type of feedback and this in turn would be a driving force in under reporting.
Future reduction of such accidents will depend on the attitudes of the
professionals in the field and improved reporting practices. Quality assurance
policies and health care doctrine are present in every health care facility.
These policies are reviewed and approved at the highest levels of hospital
administration and government however its at the care giver level that they
are not being implemented. I believed these personnel have been atiquitly
trained and thats it is all about attitude and taking your career seriously. If
the care giver puts the patients health above their reputation or standing in
a facility the reporting of accidents would increase. If ever patient were
treated as a loved one I guarantee charts would be doubled checked,
communication regarding side effects would be taken seriously. In this regard

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I believe the ratio to accidents to that of accidents reported would be more in
line due to the addition attention to detail.

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References
Walt Bogdanich, the New York Times, Radiation Offers New Cures, And Ways
to Do Harm; 01/24/10