human error and unintended events; rates of misadministration in radiation medicine; misadministrations and adverse events in other medical modalities; inappropriate and unnecessary care; and efforts that reduce misadministrations and inappropriate care.

Human Error and Unintended Events

Errors occur throughout health care: A pharmacist fills a prescription with the wrong medicine; an x-ray technician takes a film of the wrong leg; a surgeon replaces the wrong hip. The advent of complex medical technology has increased the opportunity for error even as it has increased the opportunity for effecting cures. Injuries within the health care context, including those resulting from human error, are referred to as "iatrogenic."

A landmark Harvard Medical Practice study reported that nearly 4 percent of patients hospitalized in New York in 1982 suffered an iatrogenic injury that resulted in a prolonged hospital stay or measurable disability (Brennan et al., 1991; Leape et al., 1991). The Harvard researchers conducted random samples of both acute care hospitals and patients, identifying some 1,133 adverse events from a total of 30,195 medical records reviewed. The investigators estimated that, of 2.7 million patients discharged from New York hospitals that year, 98,609 suffered an adverse event, for a rate of 3.7 percent of all hospital discharges. Based on the New York rate, the researchers estimated that in the United States more than 1.3 million people are injured annually by treatments intended to help them.

By educating health care workers, and by circumscribing their actions, human error may be minimized. However, some number of mistakes will always, unavoidably, be made, and no amount of training or double-checking can erase that fact. Recent incidents at the Dana-Farber Institute and at the University of Chicago Hospital are cases in point. Both institutions enjoy strong reputations and have quality assurance programs in place; yet, chemotherapy overdoses escaped notice in both systems, killing two patients and leaving a third permanently disabled. Although well-crafted and well-implemented regulatory programs can prevent most safety problems, they cannot completely eliminate human error.

Rates of Misadministration

This report refers to errors and unintended events that occur in the course of administering ionizing radiation in medicine as "adverse events." "Misadministrations" and ''reportable events" refer to adverse events involving NRC-regulated byproduct material and are defined at 10 CFR Part 35 (see Appendix D). One task of the committee was to determine how often adverse events occur in the use of ionizing radiation in medicine.



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