2023-11-16 09:52:42
Despite the different stages of treatment, the error was only spotted following 25 radiotherapy sessions out of the 28 planned. A blunder which might have health consequences for the patient.
“A serious error, which deeply affected the teams.” During a press briefing organized on Wednesday, the general director of the CHRU of Tours Floriane Rivière returned to the extremely rare incident which occurred in her establishment. In a press release, the Nuclear Safety Agency (ASN) reports that a woman treated for breast cancer received a series of rays on the wrong breast last spring. The error was only detected following 25 radiotherapy sessions out 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” on “the report of the initial medical consultation”, which then led to a medical error by the service. of oncology and radiotherapy of the establishment.
“The center identified that it was during the so-called contouring stage that the error occurred, the stage which consists of demarcating the area which must be treated. There is potentially a lesion in one place which was not supposed to be treated”, summarizes Pierre Bois, deputy director general of the Nuclear Safety Authority, to BFMTV.
Taking into account the overdose of the wrongly treated region and the potential risk of side effects, the ASN classified this event at level 2 on a scale of 0 to 7 going in increasing order of seriousness for the patient, synonymous with a “minimal or no impairment of quality of life.”
“A tas de processus”
Beyond the initial error, numerous shortcomings also occurred during the monitoring of this radiotherapy. Isabelle Parillot, radiotherapist oncologist, believes that these errors are linked to several factors.
“Modern techniques no longer allow the patient, in certain conditions, to realize that they are being treated in the wrong way. It is the same thing for professionals, when the treatment is started, if we do not actually check every session, you may not notice it,” she says.
Guest on BFMTV this Thursday morning, radiotherapist oncologist Avi Assouline is surprised by this error which, according to him, is “the dread of radiotherapist oncologists.”
“I would say that all processes are done to avoid these rare and serious errors. You just have to talk with the patient, with the teams, the doctors and radio technicians,” he says.
According to him, the various “processes” undertaken at the time of the medical consultation and in particular the presence of “a scar” on the breast to be treated should have raised alarm.
“There are a lot of processes that go into the treatment, you don’t end up on the radiotherapy table lying down and with a machine that will shoot on the right breast rather than the left breast. In all the processes, there are security locks to avoid this type of error,” adds the specialist.
What are the long-term risks?
While specifying that “extreme rigor in all stages and for all professionals” must be required in this type of treatment, Avi Assouline warns of the possible complications from which the patient, who did not wish to file a complaint, might suffer. and continues his treatment in the establishment.
“Ultimately there are risks of radiation-induced cancers, X-rays can paradoxically lead to cancer in the years that follow. The patient must benefit from very strict monitoring,” he points out.
This is not the first time that the Tours CHRU has been singled out for an error of the same type, which occurred earlier in the year. In France, it is estimated that there have been between 2 and 5 events of the same type since 2011, knowing that 4 million sessions are carried out each year, for 180,000 patients.
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