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RADIOTHERAPY ACCIDENT IN COSTA RICA - CAUSE AND PREVENTION OF RADIATION ACCIDENTS IN HOSPITALS






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RADIOTHERAPY ACCIDENT IN COSTA RICA - CAUSE AND PREVENTION OF RADIATION ACCIDENTS IN HOSPITALS . Module XIX. Cause and prevention of radiation accidents in hospitals. Radiation accidents with severe and even fatal consequences do occur in medical facilities
RADIOTHERAPY ACCIDENT IN COSTA RICA - CAUSE AND PREVENTION OF RADIATION ACCIDENTS IN HOSPITALS

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RADIOTHERAPY ACCIDENT IN COSTA RICA - CAUSE AND PREVENTION OF RADIATION ACCIDENTS IN HOSPITALS

Module XIX

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Cause and prevention of radiation accidents in hospitals

  • Radiation accidents with severe and even fatal consequences do occur in medical facilities

  • Human error is most common cause of radiation accidents

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Main initiating event

  • 22 Aug 1996, at San Juan de Dios Hospital in San Jose, Costa Rica, a calibration error was made for new 60-Co source

  • Consequently, the delivered dose to cancer patients was overestimated by about 60 %

  • By 27 Sept 96 115 patients treated

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Severity of effects in surviving 73 patients

  • 4 patients had catastrophic effects

  • 16 marked effects and high risk for future

  • 26 not severe at that time

  • 22 no effect of significance at that time

  • 2 underexposed patients (radiotherapy was discontinued)

  • 3 could not be seen

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Findings of IAEA team in July 1997

  • 42 patients died by July 1997 (10 months after exposure)

  • 7 deaths primarily due to overexposure

  • 22 deaths not related to the overexposure

  • 13 insufficient data

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Findings of IAEA mission in Oct 1998

  • 61 patients died by Oct 1998

    (25 months after exposure)

  • 13 deaths primarily due to overexposure

  • 4 possibly related to overexposure

  • 35 death not related to overexposure

  • 9 insufficient data

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Permanent epilation (high risk for brain necrosis)

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Effects on the skin

  • severe erythema in the sacral region

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Brain necrosis and paralysis

  • lethargy, ataxy

  • dementia

  • leuko-enceophalopathy

  • cerebral necrosis

  • deafness

  • paralysis (myelopathy)

  • spinal cord changes

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Cause and prevention of radiation accidents in hospitals

  • Significant overdoses or underdoses (errors exceeding 10% of prescribed dose) result in unacceptable severe consequences

  • Doses administered in fewer than normal sessions but with higher doses per treatment result in excessive number of early and late complications

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Distribution of expected radiation effects from standard radiotherapy protocols and clinical examinations of the surviving patients, %

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Prevention of radiation accidents in hospitals

  • Regulations should cover training and competence required to deal with potentially hazardous radiotherapy sources

  • Specific training of staff should be provided before they work in a radiotherapy unit

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Prevention of radiation accidents in hospitals

  • Calibration of radiotherapy devices should be done by appropriately trained persons and independently checked

  • When there is a high incidence and severity of acute side effects during radiotherapy treatment, further treatment should be stopped and the source calibration immediately checked

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Prevention of radiation accidents in hospitals

  • In radiotherapy accidents, the tumour dose may not be the parameter of primary interest

  • Often the biologically equivalent 2 Gy per fraction dose to radiosensitive organs, e.g. intestine, spinal cord and heart, more important

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Prevention of radiation accidents in hospitals

  • Early and reliable information and clear communication crucial to good management of radiation accidents

  • Radiotherapy records should be uniform, clear, consistent and complete

  • Use defence-in-depth methodology to test and ensure that quality assurance programme has sufficient safety layers to make accidents very unlikely

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Lessons learned Recommendations

  • Define responsibilities, develop procedures and supervise compliance

  • Implement, monitor and enforce existing regulations as soon as possible

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Lessons learned Recommendations

  • Establish and foster safety culture and provide education and training

  • Implement additional educational programmes for radiotherapy staff

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Lessons learnedRecommendations

  • Implement quality assurance and record keeping programme

  • Include

    • verification of physical arrangements and clinical aids (patients’ charts) used in treatment

    • verification of appropriate calibration and conditions of operation of dosimetry equipment

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Lessons learned Recommendations

  • regular and independent quality audit reviews of programme

  • participation in intercomparison exercises such as IAEA-WHO postal dose check service

  • procedures to take action if deviation found


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