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Radiation Therapy: The Crisis Continues

More from the New York Times on radiation safety (or the lack thereof.)  This time it's Evanston (IL) Hospital and problems involving three patients during identical stereotactic radiosurgery procedures.

Investigators found problems that should have been obvious to the rankest six sigma newbie.   Poorly-designed trays and mounts that interfere with an operator's ability to verify settings.  The need to "trick" the machine into thinking it was doing one thing when it was really doing something far more dangerous.  Complex components from multiple vendors, all kludged together.  Moving data from one computer to another and then to a third, each hand-off a failure waiting to happen. 

Says the article;
"(The) system is supposed to work this way: A treatment plan is developed on one computer, then transferred into another software system that, among other things, verifies that the treatment plan matches the doctor’s prescription. The data is then sent to a third computer that controls the linear accelerator."
Equipment manufacturer Varian offered a "...decidedly low-tech solution: a decal (!) to stick on the machines, warning operators to be extra careful in setting the radiation field."   Good grief.

Similar problems occurred at CoxHealth in Springfield, MO and at a hospital in Toulouse, France, yet  the lack of a central database for reporting errors hampered any information-sharing that might have prevented the harmful cascade.

And though a software fix has been issued, so far only 75% of affected machines have incorporated the fix.  What's wrong with the other 25%, I wonder?  Too busy meeting budget?

More on the subject of radiation safety from Steve Davis, Health Care Strategist:

Radiation Safety and Trust As A Business Strategy.

1 In 20 Radiation Therapy Patients Will Suffer Injuries.


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