Severe and Fatal Radiation Medical Errors Often Unreported

Medical errors from the use of radiation therapy can lead to severe and sometimes fatal injuries, but states lack rules requiring doctors and hospitals to disclose when radiation mistakes occur, even though they are often preventable.

The New York Times released a special report on Sunday delving into previously undisclosed cases of radiation therapy gone wrong across New York. The paper found that in New York alone, there were 621 radiation mistakes reported between 2001 and 2008. However, state officials say that other studies and evidence suggest that the number of errors may be massively underreported due to a lack of enforcement of reporting requirements.

The report comes as the FDA is investigating cases of radiation problems with CT scan procedures, after the discovery that a number of patients across the country have suffered radiation overexposure from scans performed incorrectly. The FDA released interim guidance in December for health care professionals and radiologists as it continues its investigation. The guidance advised them to review procedures and CT scan settings, and to be thorough in checking the amount of dosage prescribed for each CT scan patient.

In many cases, patients received radiation doses to the wrong parts of the body, or were subjected to radiation several times higher than prescribed. Diversified Clinical Services, the country’s larges wound care company, treated 3,000 radiation injuries in 2009 alone.

A CT scan radiation exposure study published in December in the Archives of Internal Medicine, which studied 1,119 adults who received CT scans in San Francisco in 2008, found a high amount of variation between radiation doses, with some radiation exposure varying as much as 13-fold between scans. The study estimated that 1 in 270 women who received a CT heart scan would develop cancer, compared to 1 in 600 men.

Concerned about underreporting and mistakes in radiation therapy, New York health officials sent out a warning in 2004 calling for hospitals to be more careful, and for radiation specialists to continually monitor their equipment. Many of the radiation problems resulted from software glitches and incorrect radiation settings. In many cases, the equipment indicated there was a problem or that settings were incorrect, but such warnings went unseen by technicians who never bothered to look at their monitors.

The state of New York and some other states refuse to release information on where and how medical mistakes are made, making it impossible for private citizens to determine which facilities have the best radiation therapy track records. Reporting requirements for medical errors or disciplinary procedures are also often disregarded and unenforced.

A May 2009 report by Public Citizen on physician oversight discovered that in the 17 years the National Practitioner Data Bank (NPDB) has been established, only half of all hospitals have reported any disciplinary action against doctors who may have been negligent, committed medical malpractice or otherwise received a disciplinary action on behalf of the hospital that employed them.

The recent FDA investigation was sparked by the discovery that more than 200 patients at Cedars-Sinai Medical Center in Los Angeles were subjected to overexposure to radiation. Since then, the FDA has uncovered at least 50 more radiation CT errors.

In another case this summer, the U.S. Nuclear Regulatory Commission (NRC) discovered that at least 98 veterans were given incorrect doses of radiation during brachytherapy treatments for prostate cancer at the Veterans Affairs Medical Center in Philadelphia. What some have described as a “rogue” cancer unit at the hospital botched virtually every brachytherapy procedure it performed, placing radioactive metal seeds in the wrong locations, and sometimes in the wrong organs entirely. The unit continued to perform operations even after a machine used to measure whether patients were receiving the correct amount of radiation broke down.

The doctor who headed that unit, Dr. Gary Kao, has been removed from his position. The hospital and Dr. Kao face a number of lawsuits from veterans who sometimes suffered severe injuries due to the medical mistakes.