01/10/2011 — As reported by The New York Times, three patients in an Illinois hospital were administered radiation overdoses during identical medical procedures. One patient was left nearly comatose – unable to speak, eat or walk.
The commonplace treatment all three received was stereotactic radiosurgery – or SRS – one of the fasted-growing radiation therapies. SRS therapy targets tiny tumors in the brain or spinal cord while minimizing damage to surrounding tissue. Because the radiation is concentrated and intense, it requires extreme accuracy.
The SRS was conducted using a linear accelerator, which delivers high-intensity pinpoint radiation using a heavy metal cone attachment to channel the beam to the affected area. The linear accelerator in question was redesigned by its manufacturer to enable it to perform SRS. However, the redesign allowed radiation to spill outside a heavy metal protective cone, exposing the patients to radiation overdoses. Varian Medical Systems is the world’s leading manufacturer of linear accelerators.
What happened in Illinois is not an isolated incident. Similar cases of radiation overdose during SRS have been reported throughout the country as well as in Europe.
Patient safety advocates argue that redesigned devices, such as the linear accelerator in question, often consist of different products from different companies. While some of the problems occur as a result of user error, the mix-and-match treatment delivery system, using retrofitted devices made of up different companies’ products, can lead to flaws that are inherently dangerous and difficult to anticipate. The retrofitting, some believe, has led to some of the radiation overdose problems with the SRS device that have resulted in permanent and catastrophic injuries to patients.