Accidental exposure of pregnant patients to ionizing radiation during radiation therapy planning and treatment in British Columbia cancer centers

• Main Author: Goddard, Karen Jane
• Language: English
• Published: University of British Columbia 2012
• Online Access: http://hdl.handle.net/2429/43313

This project was an interdisciplinary study of a specific medical error - inadvertent radiation therapy (RT) in the treatment of female cancer patients during early pregnancy in British Columbia. RT is very damaging to the fetus during the first trimester of pregnancy and this is a very undesirable adverse event (or medical error). I explored why this error could occur by reviewing the types and causes of medical errors in general and then studying potential errors specific to RT planning and treatment. I created and administered a questionnaire of all health care professionals (HCPs) in cancer centers across British Columbia to assess if this error had occurred. I also asked if HCPs thought this error was a significant problem and asked for their opinions regarding solutions. I examined the potential for HCP legal liability as a result of this error and existing Canadian case law regarding the inadvertent use of teratogenic agents in early pregnancy. I examined different methods for gathering data about and documenting medical errors in general and then specifically for this particular problem. I looked at the barriers to improving patient safety and how the risk of making this medical error could be reduced. As a result of my work, policy has been changed in all British Columbia Cancer Centers. A program now exists which involves check lists, signage and patient education to address this problem.