“A serious mistake, which deeply affected the teams.” During a press conference organized on Wednesday, the general director of the CHRU of Tours, Floriane Rivière, recalled the extremely rare incident that occurred in her establishment. In a press release, the Nuclear Safety Agency (ASN) reports that a woman treated by breast cancer She received a series of rays in the wrong breast last spring. The error was only detected after 25 radiotherapy sessions of the 28 planned.
How to explain this dysfunction? According to ASN, a doctor made a mistake by writing “right breast” instead of “left breast” in “the initial medical consultation report,” which then led to a medical error by the facility’s oncology and radiation therapy service. . .
“The center identified that it was during the so-called contouring stage when the error occurred, a stage that consists of delimiting the area that must be treated. Potentially there is an injury in a place that should not be treated,” summarizes Pierre Bois, deputy general director from the Nuclear Safety Authority, to BFMTV.
Taking into account the overdose of the poorly treated region and the potential risk of side effects, the ASN classified this event as level 2 on a scale from 0 to 7, in increasing order of severity for the patient, synonymous with “minimal or none.” ”. deterioration of the quality of life.”
“A lot of processes”
Beyond the initial error, numerous deficiencies also occurred during the follow-up of this radiotherapy. Isabelle Parillot, radiation oncologist, believes that these errors are related to several factors.
“Modern techniques no longer allow the patient, under certain conditions, to realize that he is being treated incorrectly. The same goes for professionals: when treatment begins, if we do not control each session, it is possible that I notice it,” he says.
Guest on BFMTV this Thursday morning, radiation oncologist Avi Assouline is surprised by this error which, according to him, is “the fear of radiation oncologists.”
“I would say that all processes are done to avoid these rare and serious errors. You just have to talk to the patient, the equipment, the doctors and the radio technicians,” he says.
According to him, the different “processes” carried out during the medical consultation and, in particular, the presence of “a scar” on the breast to be treated should have raised the alarm.
“There are many processes involved in the treatment, you do not end up on the radiotherapy table lying down and with a machine that shoots in the right breast instead of the left. In all processes, there are security measures. locks to avoid these types of errors ”, adds the specialist.
What are the long-term risks?
Although he specifies that this type of treatment must require “extreme rigor at all stages and by all professionals,” Avi Assouline warns of the possible complications that the patient, who did not want to file a complaint, could suffer and continues his speech. treatment at the facility.
“Ultimately, there are risks of radiation-induced cancer; X-rays, paradoxically, can cause cancer in the following years. The patient must benefit from very close monitoring,” he points out.
It is not the first time that the Tours CHRU has been singled out for an error of the same type, which occurred at the beginning of the year. In France, it is estimated that between 2 and 5 events of the same type have occurred since 2011, knowing that 4 million sessions are performed each year for 180,000 patients.
Source: BFM TV