(Source-euro.dayfr_.com)
A patient at the Pasteur Clinic in Toulouse suffered from a significant radiation overdose during radiotherapy treatment for recurrent pelvic cancer. This incident occurred because the previous radiation overdose sessions for the same cancer were not taken into account. The Nuclear Safety Authority (ASN) confirmed the event in an incident report.
Incident Details and Confirmation
The Nuclear Safety Authority was informed of the incident on June 20, 2024, by the Orion Group, which manages radiotherapy at the Pasteur Clinic. The event dates back to the summer of 2023, when the patient received 38 sessions of 2 grays each, equivalent to a full radiotherapy course. However, since the patient had already undergone radiotherapy for the same cancer, the earlier sessions should have been factored in to prevent overirradiation of nearby organs. This oversight led to the radiation overdose.
Serious Classification by the ASN
The incident resulted in major lesions in the irradiated areas, necessitating surgical intervention and causing a significant decline in the patient’s quality of life. This led to the discovery of the overdose. The ASN has classified the event as level 4 on the ASN-SFRO scale, which ranges from 0 to 7. Level 4 signifies that the event endangered the patient’s life or exposed them to severe complications or disabilities.
Orion Group’s Response and Analysis About Radiation Overdose
The Orion Group, a leading private oncology-radiotherapy group in Occitanie, operating six treatment centers in Haute-Garonne and Tarn-et-Garonne, and treating over 3,300 patients annually, has initiated an analysis of the circumstances and causes of the incident. In a press release, the Orion Group acknowledged the gravity of the situation and held an exceptional Feedback Committee meeting on June 28th, overseen by Dr. Guillaume Janoray, to understand the factors that led to the locoregional re-irradiation.
Corrective Measures and Support
The Orion Group has undertaken a series of corrective measures to prevent such incidents in the future. This includes a review and reinforcement of existing procedures and the implementation of a corrective action plan to minimize the risk of recurrence. Additionally, the group has offered psychological support to its staff and emphasized the longstanding professionalism of its teams in treating adult cancers.
ASN’s Monitoring and Verification
The Nuclear Safety Authority will continue to monitor the situation and ensure that the corrective actions identified by the Orion Group radiation overdose are effectively implemented. The ASN’s oversight aims to guarantee that such incidents do not reoccur and that patient safety remains a top priority.
This incident highlights the critical importance of accurate treatment records and vigilant oversight in radiotherapy to prevent harmful overdoses. The response by the Orion Group and the ongoing monitoring by the ASN are essential steps in addressing the issue and safeguarding patient health.
