What did you just do, page 2

In 2004 Toft chaired a review of a patient safety incident in the Department of Radiotherapy at Cookridge Hospital in Leeds. The patient had received the wrong dose of radiotherapy 14 times before it was discovered that one of the prescribed parameters had not been put into the computer database, which controls the linear accelerator and delivers the treatment.

The radiographers had a robust double-checking protocol in place but the error went undetected by several different people at different times. They were neither inattentive nor apathetic; they simply did not see the error.

A similar incident occurred in Seattle where a patient received 7,600 rads of radiation instead of the prescribed 3,600 rads, when the same radiation filter was omitted from the linear accelerator. Mike Odlaug, director of the x-ray control section of the Washington Department of Health commented that what was unusual was that it went uncorrected for 20 treatments.

Toft says: “The error was right before their eyes, the screen would have said filter out, but for 20 treatments they thought it said filter in. This is an example of IA which undermines a standard challenge-response protocol.”

Another example of suspected IA involved 16-year-old Lisa Norris, who received 17 overdoses of radiotherapy for a brain tumour at the Beatson Oncology Centre (BOC) in Glasgow last year. The report by the Scottish Executive said: “Mistakes were made by BOC treatment-planning staff against a background of circumstances that were not conducive to error-free working”.

According to Toft, IA could have been the reason why errors were missed because the working environment was similar to those where IA had been previously identified. When asked about this the Scottish Executive said: “The Inspectors’ report avoids speculation on psychological factors”.

Cases as glaring as these are relatively infrequent: the BBC reported that over the past 20 years 46 incidents had occurred where the patient had received the wrong radiation treatment and the treatment had continued in only 12 of them. The incident in Seattle was the first known treatment overdose in more than 10 years. However, as IA is a psychological condition it is hard to detect and may be the root cause of many more errors in the healthcare system. Toft says the causes of IA include:

• high workload
• stringent time pressures
• staff shortages, and
• interruptions and distractions.