Following a medical error in Bordeaux, a cancer patient was treated on the wrong side for 11 sessions.
- The patient was to undergo 22 radiation therapy sessions in total.
- The event was classified at level 2 on the ASN-SFRO scale, whose increasing order of severity goes from 0 to 7.
To err is human, but it can be serious. In February 2021, the Bordeaux Nord radiotherapy SARL experienced this. A medical professional realized that a cancer patient was treated on the wrong side for half of his external radiation therapy treatment.
A discovery “fortuitous”
This patient, whose identity is withheld for reasons of medical secrecy, received X-rays at the level of the parotid gland. Located under the ears, on both sides of the mouth, its role is to secrete saliva. In his case, the doctors treated the left parotid gland instead of the right. “The laterality error was incidentally discovered after the 11e session, by a technician who wondered about the presence of a dressing on the right while the treatment was carried out on the opposite sideexplains the Nuclear Safety Authority in a communicated. After verification by a medical physicist, the laterality error was confirmed and the treatment was stopped.” The patient was informed of this error and its potential consequences, and then the treatment resumed on the safe side.
“The event resulted from an erroneous indication by a doctor of the side to be treated and this error was not seen“, specifies Jean-François Valadeau, head of the local nuclear pole of the Bordeaux division of the Nuclear Safety Authority, to The Dispatch. In its report, the ASN specifies that the patient’s file contained divergent information. “No verification of laterality was carried out when delivering the treatment”adds the text.
ASN carried out an inspection following this incident in February 2021. It noted that “corrective actions” have been put in place to make procedures more secure. “Nevertheless, it appears from this inspection that the service must make its document management more reliable and will have to assess the adequacy and effectiveness of the security provisions in place.however, says the ASN.
Not so rare mistakes
At the end of its report, the nuclear safety authority recalls that these incidents are frequent. In 2013, six events of this type were recorded in France. Several causes are put forward: the organization of work, especially in certain busy periods, laterality control methods that vary, technical problems or the constraint linked to deadlines. In France, medical error is recognized by law. Victim patients have ten years to initiate proceedings, after the consolidation of their state of health.
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