A patient from the greater Montpellier cancer center was treated with eight radiotherapy sessions on the wrong breast last March. The Nuclear Safety Authority is warning of “the increase in this type of error”.
It is a medical error that may seem improbable, yet very real. On March 25, the Nuclear Safety Authority (ASN) was alerted of a “significant event” occurred at the Greater Montpellier Cancer Center (CCGM): a patient, treated for breast cancer, received radiotherapy sessions on the wrong side.
Of the twenty-five external radiotherapy sessions planned, eight were carried out before the laterality error was detected, “At during a weekly follow-up consultation, in the event of the appearance of side effects on the side opposite to that of the tumor”as reported by ASN in a press release dated April 23.
The Nuclear Safety Authority reports that the error “occurred during treatment preparation”and “the subsequent stages, including various validations during the preparation of the treatment then its execution, did not make it possible to [l’]identify”.
ASN asked the radiotherapy center to analyze the root causes of this event, in particular in order to understand why the safety barriers put in place during the different stages did not make it possible to detect the error.
Nuclear Safety AuthorityCommunicated
The ASN classified this incident as level 2 on the ASN-SFRO scale, which assesses the severity of radiation protection events affecting patients from 0 to 7. Level 2 corresponds to a “event causing or likely to cause moderate damage to an organ”causing a “minimal or no impairment of quality of life”. Between two and five events of this level have been recorded on average by the Nuclear Safety Authority since 2011.
However, the authority says it notes “the resurgence of this type of error”. On March 26, the day after the Montpellier incident, it was the Dijon cancer institute which noticed a laterality error. A patient had just undergone 20 radiotherapy sessions on the right breast, while she had just had surgery on the left breast for a tumor.
Questioned by France 3 Bourgogne, Doctor Édouard Lagneau, oncologist and radiotherapist at the institute, admits an error “quite incomprehensible”. “This kind of error can happen, but usually there are always elements that end up alerting us,” continues the doctor. According to him, the The patient said she reported the problem to a technician at the start of the protocol, without it being taken into account.
As she didn’t get a response, she didn’t say anything again. She didn’t do it again during the following sessions, she says she didn’t dare.
Édouard Lagneau, oncologist-radiotherapist at the Dijon Cancer InstituteFrance 3 Burgundy
The oncologist affirms that his patient does not present any after-effects of this error, nor any “loss of chances” regarding the treatment of her affected breast. She apparently decided not to file a complaint.
The Dijon cancer institute, as well as the greater Montpellier cancer center, have both been ordered by the Nuclear Safety Authority to put in place “corrective actions” in their protocols, so that this type of incident can be avoided in the future.
Édouard Lagneau reports that in Dijon, “A specific validation item on the right or left side” was implemented in the processing validation process, “a measure even more restrictive than until now”.
Contacted by France 3 Occitanie, the greater Montpellier cancer center has so far not responded to our requests.
