When going nuclear, don't misunderestimate misadministration

Published on
July 3, 2009

Misadministration. When a physician has made a horrible mistake with wide-ranging ramifications, the terms "negligence," "malpractice" even "incompetence" might come to mind. Now this wonderful euphemism glides onto the scene, draping the wreckage in a filigree of blamelessness, warding off trial lawyers and investigative journalists.

It's a good word to use when hunting for relevant documents in the Nuclear Regulatory Commission's database. I encouraged Antidote readers to spend some time with the NRC's ADAMS database in a post about Walt Bogdanich's story about the Philadelphia VA hospital last week, a story that prompted a U.S. Senate hearing faster than you could say brachytherapy. I took my own advice and spent some time looking for cases. There's a fascinating case about Backus Hospital in Norwalk, Conn., to be found.

On July 4, 1994, Dr. Douglas W. Johnson, a U.S. Air Force radiation oncologist who worked as an NRC consultant, wrote a letter to Dr. Ronald Bellamy, the commission's branch chief in King of Prussia, Pa.

It begins: "Attached is a copy of my medical impact assessment of the recent Backus Hospital misadministration event."

In this case, this is what "misadministration" looks like.

A 73-year-old man went in to have his prostate cancer treated at Backus. He was supposed to receive a radioactive seed implant at a dose tailored to his disease. Instead, he received radioactive seed implants that were 10 times the recommended dose.

Johnson calls the mistake "life-threatening to the patient." He goes on to say, "undetected and without mitigative actions, the doses to the rectal, perineal, prostatic, and bladder tissues would have far exceeded tolerance. I am unaware of any recorded similar cases to compare with..."

Fortunately, they immediately performed a second surgery to remove some of the seeds. By the time they went in, three of the seeds had "migrated," meaning they moved or were placed in the wrong spot to begin with. They were near a sensitive cluster of nerves and threatening to paralyze the patient's leg.

The second surgery, though, meant that the patient lost his prostate, meaning that he likely will have side effects from that over time. They also removed part of his colon. And, in the following days, doctors went in again to remove more seeds. In Johnson's estimation, the patient could expect cysts, swelling and bleeding from his rectum and likely permanent damage to some of his sacral nerves. He also could end up with a hypothyroid condition.

One of the best parts of this document is how it breaks down exactly what was supposed to be done in this case and then how it deviated from the norm. It's rare that you see such a clear explanation of the standards and then the failure to meet them. Here's the clearest and most damning sentence:

"Although details of the sequence of events leading to this event are outlined by other team members, the critical deficit lay in the failure of anyone (nuclear medicine staff, dosimetrist, physicist, physician) to ever compare the strength of seeds received to the strength of seeds ordered by the Radiation Oncologist."

The letter also provides a nice summary of records you should try to get your hands on when you're investigating these types of cases:

1. Backus Hospital inpatient hospital chart.

2. The implant pre-plan. This was key in Bodgdanich's reporting.

3. Post-implant and post-mitigative surgery dosimetry. This was how they found out something had gone wrong.

4. Backus Hospital contracts with consulting Yale/New Haven Medical Center. Who's responsible for what and who is getting paid for what.

5. Backus Hospital Radiation Safety Committee minutes. One hopes these would be candid discussions.

6. Various attendant training forms and notes from preliminary NRC investigation team.

Most of these items you will probably have to get through the patient. Even if you are dealing with a public hospital, chances are slim that they will hand you these documents. Unless, of course, you already have been making friends over there.

Don't know how to make friends in a hospital? I will talk about that in later posts.