In Montpellier, a woman with breast cancer received eight sessions of radiotherapy on the wrong breast. The appearance of side effects on her healthy breast alerted health professionals.
- In Montpellier, a woman received eight sessions of radiotherapy on the wrong breast.
- Side effects on this healthy breast alerted professionals.
- The nuclear safety authority is warning of an increase in these medical errors.
It took eight sessions for the doctors to realize their error: at the greater Montpellier cancer center, a woman suffering from breast cancer carried out eight radiotherapy sessions on the wrong breast. “A laterality error (right-left inversion) occurred during treatment preparation, when selecting the target organnotes the Nuclear Safety Authority in a communicated. Subsequent steps, including various validations during the preparation of the processing and then its execution, did not make it possible to identify this error. Eight treatment sessions out of the twenty-five planned were thus carried out on the wrong side.”
Radiotherapy: what are the consequences of this medical error?
Side effects began to appear on that breast, which made it possible to spot the error during a weekly follow-up medical consultation. “The patient was informed of the error and its potential consequences. specifies ASN. The incident was classified as level 2 on the ASN-SFRO scale, which aims to “to inform the public about radiation protection events affecting patients as part of an external radiotherapy and brachytherapy procedure”. This category includes acute effects or moderate late effects.such as moderate radiation stenosis, mild tissue alteration (cutaneous fibrosis), or minimal or no impairment of quality of life., explains ASN. At the same time, the patient received a new treatment plan proposal to treat the breast that should have been treated.
Error during radiotherapy: a similar case in Burgundy
This case is not isolated. At the end of March, ASN was informed of a similar error at the Burgundy Cancer Institute. “A laterality error (right-left inversion) occurred during treatment preparation, resulting in the contouring of the right breast instead of the left breast, which led to the entire treatment plan being carried out on the wrong side, i.e. 20 sessions”indicates a communicated. The authority asked the two establishments “to analyze the root causes” of these events for “understand why the security barriers put in place during the different stages did not detect the error”.
Faced with the observation of a “resurgence of this type of errors”she calls on radiotherapy professionals to “evaluate the robustness of the safety barriers put in place to protect against laterality errors”. In 2010 and 2013, 13 similar incidents were recorded by ASN.
