Medical Errors and Medical Physics
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1 Medical Errors and Medical Physics Michael Herman Ph.D. Peter Dunscombe, Ph.D. Bruce Thomadsen, Ph.D. Outline Introduction Are Errors A Problem? Are Medical Physicists Part of it? Quantitative Assessment of Causation and Prevention Specific Examples and Instances Role of JCAHO Impact on Medical Physics Training/Practice Patient Safety: The extent of the problem Data used in the IOM Report, To Err is Human 1999 And some other From the Harvard Medical Practice Study* 1984 study of the charts of 50,000 random discharges in 51 NY state hospitals Adverse events cause increase in hospital time in 3.7% of the cases 58% were due to preventable errors 27.6% due to negligence *Brennan, Leape, et all. N Engl J Med 324: (1991). 1
2 Harvard Study Continued Almost all cases included disability lasting more than 6 months 13.6% led to death 2.6% to permanent disabilities About 1/4 of negligent failures led to death. Harvard Study Continued 19% Drug complications 14% Wound infections 13% technical complications Colorado and Utah Study* 1992 Study of 15,000 discharges from 28 hospitals Adverse events in 2.9% 53% preventable errors 29.2% due to negligence 8.8% led to death (same % for negligence and not) Differences between the studies Possibly due to: Average health of the populations Differences in the health care systems *Thomas, Studdert, et al. Inquiry 36: (1999) 2
3 Extrapolation to the Whole Country Projections of deaths/year due to errors using the: NY study => 98,000 Colorado/Utah study => 44,000 Some papers suggest that these are overestimates, and others that these are underestimates. Either way, there is a problem. How Bad? Using the lower number, medical errors would be the 8 th leading cause of death! It May Be Worse Steel et al (N Eng J Med 1981) 815 hospital pts 36% of patient in hospital had hospital-acquired (iatrogenic) problems, 9% life threatening 2% died. Andrews et al (Lancet 1997) 1,047 ICU pts 45.8% adverse events 17.7% event causes disability or death And A study of the ER found an average of 2 errors per minute A study of hospital deaths found 14 to 27% from errors* A study** of surgical patients, 2.7% had surgical deaths due to errors; of other deaths of these pts in hospital, 7.5% from errors. *Dubois and Brook. Ann Intern Med **McGuire et al. Arch Surg
4 Medication Errors Error rates have been measured between 0.3% and 6.5% For 7Gigascripts/y nationally, that would be 21M errors/y at the least! Other studies have found 15-30% hospital medication administrations have some error. Medical Physics Calibration Data Corruption Data Communication Events related to equipment affecting many patients Radiation measurement systems: Calibration of reference system * Intercomparison with secondary system * Routine use * * - Physicist involved? Equipment Continued Treatment machine Commissioning (acceptance) * Calibration (annual) * Constancy check (daily, weekly) * Malfunction of machine Incorrect use IAEA Report - Lessons Learned from Accidental Exposures in Radiotherapy,
5 Equipment Cont d Treatment planning system Commissioning and input of basic data Routine use * * Patient Specific Errors Miscommunication of prescription Error in use of images Incorrect Documentation Calculation of treatment time or monitor units Incorrect use of treatment planning system Patient identification Documentation of patient setup Incorrect operation of treatment machine Final review at completion of treatment Some Reasons Inadequate Resources Personnel, Equipment Inadequate Training Human-Machine interfaces Poor Communication/Documentation Patients exposed to high radiation levels A machine's programming error caused the problem for 10 months. Published April 1, 2005 An improperly installed machine exposed 77 patients with brain tumors and malformations to higher-than-prescribed radiation levels for nearly a year before the mistake was caught. Federal inspectors detected the error on March 7, after 10 months during which the machine had been used. They determined that the machine, installed in May, gave patients radiation doses 1.5 times more powerful than prescribed amounts. 5
6 Gamma Knife Miscalibrated Service Engineer inadvertently changed source calibration date. ~ 2003 Our Responsibility! Safety and QA program From Draft SCOPE OF PRACTICE During a software upgrade the date of source calibration was changed (to something like 3 years prior) No routine QA in place to catch this error. For months patients were treated with incorrect (and very high) doses. The essential responsibility of the Qualified Medical Physicist s clinical practice is to assure the safe and effective delivery of radiation to achieve a diagnostic or therapeutic result as prescribed by a licensed practitioner in patient care. To Peter Dunscombe Implications on Training Proper Training is Essential Too Many Medical Physicists Placed in Practice sans Proper Training Safe and Effective Practice is our responsibility. QA documentation. 6
7 Training Essentials Graduate Degree Physics, Medical Physics Accredited Didactic Training in Medical Physics Clinical Training in Medical Physics Board Certification (Expand these) Provides a foundation of individuals who will be competent and accountable for carrying out safe procedures in patient care. Implications on Practice QA and Safety is Paramount Complex, High technology, Pressure to produce Safeguards MUST be in place Team must work together.. Summary/Discussion 7
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