Hospital fined in 2 radiation dosage errors

No adverse effects seen in two cancer patients at Anne Arundel Medical Center

April 11, 2008|By Frank D. Roylance | Frank D. Roylance,sun reporter

The Anne Arundel Medical Center, in Annapolis, has been fined $20,000 by the Maryland Department of the Environment after reporting two separate incidents in which cancer patients received the wrong doses of radiation.

The second mishap occurred in November, months after the hospital was ordered to take corrective action after a similar incident in May, MDE officials said.

The fine was the maximum allowed for two such incidents, according to Roland Fletcher, the MDE's program manager for radiological health.

"We're talking about repeat violations, and that usually causes the penalty to be higher," Fletcher said. In both cases, he said, "procedures established were not being followed."

Neither patient had any adverse health effects from the incorrect exposures, he added.

Hospital spokesman Justin Paquette said both patients are still being treated at the facility. Citing federal privacy laws, he declined to discuss whether they received too much or too little radiation, what type of radiation they received or the nature of their illness.

MDE officials said they received reports of two similar incidents last year of "misadministration" of radiation by cancer care providers.

In one, Maryland Regional Cancer Care, free-standing cancer care centers with locations in Bowie, Rockville and Silver Spring, was fined $2,000.

The John Marsh Cancer Center, at Washington County Hospital in Hagerstown, also reported a misadministration incident, but the MDE has not yet concluded its action in the case, said department spokeswoman Kim Lamphier.

Both mishaps at the Anne Arundel Medical Center occurred because a hospital staff member failed to follow established procedures, Fletcher said.

In a prepared statement, Paquette said, "We take very seriously any misadministration in treatment planning. Both patients were immediately notified, as was the state. Even before the state responded, we did a thorough internal investigation, and we have made additional proactive changes to enhance quality in treatment."

Fletcher said the MDE, too, ordered "corrective action ... immediately."

The MDE typically participates with hospital radiation safety committees in re-evaluating their procedures, and "we assist them in any way" to take corrective actions.

The agency then considers what, if any penalties to impose.

"We were processing the first penalty when the second one occurred," he said. It was "essentially a repeat of the first."

The penalty actions were combined, and the fines ordered on Feb. 26. They were made public on Wednesday.

Asked how such a mistake could have occurred a second time after corrective action had been ordered, Fletcher said, "It's hard to say ... You're often dealing with different people on the staff. You're dealing with tired workers ... Often the patient load is so great, everybody is rushing around, and they take shortcuts."

Martha Harlan, director of public relations at Anne Arundel Medical Center, said that "after the first incident, a process was put into place, all the staff was trained. And in [November] one staff member did not follow the protocol. That staff member is no longer with our organization."

frank.roylance@baltsun.com

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