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Format: 04/23/2014
Format: 04/23/2014

News

Pittsburgh Business Times: Safety of radiation treatment becoming a national issue

Tuesday, February 16th, 2010

  By Kris B. Mamula 

The region’s two largest providers of radiation oncology care reported nine errors in radiation treatment for cancer between 2004 and 2009, representing a fraction of the total treatments done during the five-year period, but lifting the curtain on a lesser known kind of medical error.

The safety of radiation treatment became an issue in recent weeks as the New York Times published a series about serious and fatal errors in delivering radiation during cancer treatment in Texas, New Jersey, Louisiana and elsewhere. In response, the American Society for Radiation Oncology earlier this month unveiled a safety improvement program, which would create a central database for reporting mistakes, expanding educational training for technicians and enhancing equipment accreditation requirements.

The changes come at a time when hospitals are trying to shrink the number of medical mistakes, which claim the lives of as many as 98,000 people annually, according to the Institute of Medicine. It can take years before problems associated with radiation overexposure emerge.

Between 2005 and 2009, the University of Pittsburgh Medical Center reported eight radiation treatment errors, while West Penn Allegheny Health System reported one instance to the state Department of Environmental Protection in 2004.

These errors in using linear accelerators, the devices that deliver radiation, were among 42 reported statewide. DEP requires reporting when radiation exposure exceeds 20 percent and 30 percent of the prescribed dosage.

“Every one of these events is one event too many,” said Dr. Dwight Heron, vice chairman of radiation oncology at UPMC. “We’re all human. Errors happen. What’s important is what you do to prevent them in the future.”

No injuries resulted from any of the errors at UPMC, and, in each case, the patient and referring physician were told. UPMC thoroughly investigates errors and corrects practices that lead to mistakes, Heron said, and corrective actions are filed with the state, as required by law.

UPMC’s 21 radiation treatment centers in the region perform some 150,000 treatments annually, Heron said, making the error rate a fraction of a percent in radiation oncology.

There’s always the potential for a mistake, said Gregory Ross, a former radiation therapist and president of Shadyside-based D3 Radiation Planning, which develops treatment plans for doctors at UPMC and other institutions.

“But the number of clinically significant errors is extraordinarily low,” he said.

West Penn Allegheny Health System reported radiating the wrong patient in June 2004, which resulted in a firing, an improved method of verifying the identity of a patient and extra training for staff, according to the DEP.

The West Penn Allegheny Health System Radiation Oncology Network has not reported an error since 2004 at its nine regional cancer centers, said Dr. Dave Parda, network chairman. The network performs some 50,000 treatments annually.

“You can have random human errors and machine faults, but when you have good quality control, that doesn’t translate into harm to the patient,” he said. “It really takes constant mindfulness.”

 

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