Last spring, a patient from CHRU Bretonneau (Tours) suffering from a cancerous breast tumor underwent radiotherapy on the wrong breast.
- A patient from the Bretonneau CHRU in Tours, suffering from breast cancer, received her radiotherapy treatment on the wrong breast.
- The laterality error (right-left inversion) was discovered at the 25th session.
- The establishment had already been confronted with this type of error.
Here is a particularly worrying medical error revealed by France 3 Center Val de LoireNovember 10, 2023. The oncology and radiotherapy department of the Bretonneau CHRU in Tours carried out radiotherapy on a patient with a malignant tumor on the left breast instead of the right.
Radiotherapy: the bad breast has been treated
The medical error, of which the breast cancer patient was the victim, was noted by the Nuclear Safety Agency (ASN) last July. In his incident noticethe organization specifies that “the laterality error (right-left reversal) occurred during treatment preparation“. That is to say, it took place before the start of the protocol which was based on a daily ionizing radiation session for 28 days.
However, “the various subsequent stages, including contouring and the various validations, did not make it possible to identify this error which was only detected at the end of the 25e session”deplores ASN.
This incident was classified as level 2 (out of 7) on the ASN-SFRO radiotherapy event scale, taking into account the overdose of radiation received in the wrongly treated region and the potential side effects for the patient. In addition to the delay in treatment for the existing malignant tumor, one of the risks incurred by the patient is radio-induced cancer. The latter was informed of the error and its potential consequences. “A new treatment plan was proposed to treat the breast that should have been treated”specifies ASN.
Breast cancer: a similar error has already occurred in the establishment
An investigation is being carried out into this incident. It should help to understand “why the checks carried out during the processing preparation stages did not detect the error” and to determine the measures to take to avoid it. It seems all the more necessary as this is not the first time that the hospital has faced such an event.
“Already faced with this type of laterality error, the establishment had started reflections on the process to guarantee the accuracy of the information transcribed on digital media and had taken action”specifies ASN in its press release.
