76 patients overradiated at Missouri hospital

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A Missouri hospital overradiated 76 patients with brain cancer between 2004 and 2009 because of an error in the calibration of an advanced radiation therapy system.

The hospital, CoxHealth of Springfield, said this week that the 76 patients receiving treatment from the hospital’s BrainLab stereotactic radiation therapy system were exposed to radiation that exceeded the intended therapeutic dose by approximately 50 percent.

"In the simplest of terms, when the BrainLAB stereotactic system was put into service in 2004, we believe that the CoxHealth chief physicist responsible for initially measuring the strength of the radiation beam and gathering the data used to calibrate the equipment, chose the wrong measurement device . . .,” said John Duff, MD, senior vice president of hospital operations. “This is a very complex process, and unfortunately, in spite of this physicist's experience and training, an error was made.”

According to CoxHealth, the chief physicist who made the calibration error no longer works for the hospital.

Duff said that the calibration error was discovered last year when a second CoxHealth physicist received training on the BrainLab system. The hospital then began an internal investigation and stopped accepting new patients into the BrainLab stereotactic program. When the hospital discovered cases in which the difference between the prescribed and received radiation dose exceeded that which is considered to be therapeutic, it suspended the BrainLab program for all patients.

“We hired an outside physics expert to begin an independent re-analysis of all 152 patient cases treated in the BrainLAB stereotactic program since its start in 2004,” said Duff. “We received the majority of the results on Feb. 16 and immediately began calling patients to request in-person meetings to notify them of their results.”

CoxHealth said that because in many of the excess radiation cases the patient prognosis was poor when treatment began, “it's premature to say if the overexposure had any impact on their current health condition, or if deceased, if it had any contributing factor to their deaths.”

The hospital said it will pay for additional follow-up exams, testing, support and treatment recommended by radiation oncologists that has resulted from the radiation exposure they received. In addition, the hospital has suspended the use of the BrainLab system indefinitely while the entire program is audited.

"We have implemented a system-wide 'Safety Assurance Technology' initiative, in which we are checking --and double-checking -- all of the technology and equipment used in not only the radiation oncology department, but also our radiology and surgical services,” said Robert Bezanson, president and CEO of CoxHealth. “These three areas are where most of our life-saving technology is concentrated, and we want to assure our patients and ourselves that an inadvertent human error won't impact people in this manner again."