Despite the different treatment phases, the error was only discovered after 25 of the 28 planned radiotherapy sessions. A blunder that can have consequences for the patient’s health.
“A serious mistake that has deeply affected the teams.” During a press conference organized on Wednesday, the general director of the Tours CHRU, Floriane Rivière, revisited the extremely rare incident that had occurred at her facility. In a press release, the Nuclear Safety Service (ASN) reports that a woman has been treated breast cancer received a series of rays on the wrong chest last spring. The error was only discovered after 25 of the 28 planned radiotherapy sessions.
How to explain this dysfunction? According to ASN, a doctor made a mistake by writing ‘right breast’ instead of ‘left breast’ on ‘the report of the first medical consultation’, which subsequently led to a medical error at the institution’s oncology and radiotherapy department. .
“The center found that the error occurred during the so-called contour phase, the phase that consists of defining the area to be treated. There may be a lesion in one place that should not have been treated,” summarizes Pierre Bois , Deputy Director General of the Nuclear Safety Authority, at BFMTV.
Taking into account the overdose in the improperly treated area and the potential risk of side effects, the ASN classified this event at level 2 on a scale of 0 to 7, increasing in order of severity for the patient, synonymous with a ‘minimal or no impairment of the quality of life.”
“A lot of processes”
In addition to the initial error, numerous shortcomings occurred during the monitoring of this radiotherapy. Isabelle Parillot, radiation oncologist, believes that these errors are related to several factors.
“Modern techniques, under certain conditions, no longer allow the patient to realize that he is being treated incorrectly. The same applies to professionals: when treatment is started, if we do not actually monitor each session, we may not notice it” , she says.
Radiation oncologist Avi Assouline is a guest on BFMTV on Thursday morning and is surprised by this error, which he says is ‘the fear of radiation oncologists’.
“I would say that all the processes are in place to prevent these rare and serious errors. You just have to talk to the patient, to the teams, the doctors and radio technicians,” he says.
According to him, the various “processes” taking place at the time of the medical consultation, and in particular the presence of “a scar” on the breast to be treated, should have caused alarm.
“There are many processes involved in the treatment, you do not end up lying on the radiotherapy table with a machine that shoots at the right breast instead of the left breast. All processes have safety locks to prevent these types of errors,” adds the specialist.
What are the long-term risks?
While specifying that this type of treatment must require “extreme precision at all stages and for all professionals”, Avi Assouline warns of the possible complications that the patient, who did not want to file a complaint, could suffer. treatment in the institution.
“Ultimately, there are risks of radiation-induced cancers. X-rays can paradoxically lead to cancer in the years that follow. The patient must benefit from very strict monitoring,” he emphasizes.
This is not the first time that the Tours CHRU has been singled out for an error of the same type, which occurred earlier this year. In France, it is estimated that there have been between two and five events of the same type since 2011, knowing that four million sessions are carried out annually for 180,000 patients.