Errors that are difficult for affected patients to forget. The Nuclear Safety Authority, an independent organization acting on behalf of the State, warned on Tuesday, April 23, about “the resurgence” of “lateral” errors in radiotherapy. A communication that follows several cases of patients who received radiotherapy in the wrong breast.
A patient at the Cancer Institute of Burgundy (ICB) in Dijon received 20 sessions of radiotherapy to the wrong breast in February, France 3 Bourgogne reports. This woman was going to receive radiotherapy sessions on her left breast, after having undergone surgery, Edouard Lagneau, ICB radiation oncologist, explained to France 3.
“However, during the preparation of the treatment there was an error: the doctor wrote ‘right breast’ instead of ‘left breast’. Normally, there are a certain number of procedures and checks, but here this was not detected,” he said.
“It is very multifactorial. In fact, it is quite incomprehensible. This type of error can occur, but normally there are always elements that end up alerting us,” adds the radiotherapist.
The patient reported the error.
An error that is all the more incomprehensible because the patient realized this error. “The patient says that she reported it once, but since she did not get a response, she did not say anything again afterwards. She did not mention the topic again in the following sessions. She says that she did not dare,” according to Edouard. Lagneau.
This error was only formally detected during the post-treatment follow-up consultation, according to the ASN. The organization assessed the severity of this incident at level 2 (out of 7) on its radiotherapy event scale. This means it is likely to cause moderate impairment of an organ or function, with little or no impairment to quality of life. The ASN counts between 2 and 5 on average per year since 2011.
“In this phase, the treatment did not generate any side effects, except for some skin effects, such as redness on the chest treated by mistake, but which were subsequently resolved,” Edouard Lagneau explained to France 3. The establishment “considers that there is no effect secondary”. consequences, nor loss of opportunity due to the delay in the treatment of her pathological breast.” But the radiotherapist recognizes that the patient suffered a “psychological trauma.”
The center must still determine why the error was not detected during processing and send a report to the ASN within two months detailing an analysis of the causes of this incident and “the planned corrective actions.”
Another incident in Montpellier
This Tuesday, the ASN reported a similar incident at the Greater Montpellier Cancer Center (CCGM), which it was informed of on March 25. One patient received eight of the 25 planned radiotherapy sessions in the wrong breast. “The error was detected during a weekly follow-up consultation, due to the appearance of side effects on the opposite side of the tumor,” says the ASN, which also classified this incident at level 2 of the ASN-SFRO scale.
In 2023, at the CHRU in Tours, a woman underwent 25 sessions of radiotherapy to the wrong breast. According to ASN, a similar error also occurred in Villeurbanne last year. Errors that are not trivial in the context of a treatment that can alter healthy cells and delay the receipt of appropriate treatment for the disease.
For this reason, the Nuclear Safety Authority is once again asking radiotherapy professionals to “evaluate the robustness of the safety barriers in place to protect against laterality errors.”
Source: BFM TV
