NY Times expose: Radiation errors a ticking time bomb

3/5/2010

Complex, computer-controlled devices are fundamentally changing medical radiation and raising safety issues, the New York Times reported recently. It noted new technology 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.” Even scientific societies haven’t been able to keep up with the rapid pace of technical improvements. “Hospitals, too, are lagging, sometimes failing to provide the necessary financial support to operate the sophisticated devices safely. And manufacturers sometimes sell machines before all the software bugs are identified and removed,” the newspaper added. It says precise numbers are hard to come by because radiation accidents are chronically underreported, there is no national database, and states vary in their definition of an incorrect radiation dose. But contributing to widespread unease are instances like the ones reported late last year in which more than 300 patients in four hospitals – and possibly many more – were overradiated by powerful CT scans. “The overdoses were first discovered at Cedars-Sinai Medical Center, a major Los Angeles hospital, where 260 patients received up to eight times as much radiation as intended. Those errors continued for 18 months and were detected only after patients started losing their hair,” the Times reported. It adds the FDA is still struggling to understand and untangle the physics underlying the flawed protocols. “The incidents not only highlight the peril of placing too much trust in computers, they also raise questions about the training and oversight of medical physicists and radiation therapists. Despite the pivotal role medical physicists play in ensuring patient safety, at least 16 states and the District of Columbia do not require licensing or registration,” the newspaper said. Even sophisticated medical centers may not have their act together. The Times reported than in 2008 among hospitals seeking admission into clinical trials, nearly 30% failed to accurately irradiate an object, called a phantom, that mimicked the human head and neck. The hospitals were using a now common form of machine-generated radiation called Intensity Modulated Radiation Therapy, or I.M.R.T.