Cancer Patients Receive Higher Radiation Doses Because of Error

April, 2005

Seventy-seven patients at a cancer treatment center in Florida, were exposed to radiation levels 50 percent stronger than they were supposed to receive for nearly a year because a machine was improperly installed.

Federal inspectors detected the error on March 7 at the H. Lee Moffitt Cancer Center & Research Institute in Tampa, 10 months after the machine was installed, officials said. It is typically used to treat patients with inoperable brain tumors and a poor prognosis for survival, according to a state agency.

Moffitt officials acknowledged the error, more than three weeks after physicists with the federal Radiological Physics Center discovered it.

"We at Moffitt take full responsibility for the programming error," center director and CEO Dr. William Dalton said. "I'm sorry and all of us are sorry it happened."

The delay was necessary to allow Moffitt officials to meet privately with the patients, Dalton said. Of the 77 patients, 12 have died and two could not be reached because they were out of the country.

"Some people were having side effects, but overall, they were within the normal range of side effects of radiation treatments," Dalton said. "We aren't seeing unanticipated levels of side effects."

Dalton said side effects to overexposure could include headaches and speech and memory loss. It could take three months to a year for these symptoms to emerge.

According to a report by the Florida Bureau of Radiation Control, a physicist installing the machine used the wrong formula, causing the machine to release 50 percent more radiation than prescribed.

"He made the same mistake three times. There was no good explanation," said Dr. Harvey Greenberg, Moffitt's division director of radiation oncology.

"They were supposed to have a second physicist independently verify the calibrations of the first physicist," said Bill Passetti, the bureau's chief. "It looks like the second verification wasn't performed, which is a violation of the facility's protocol and procedures."

From now on, Greenberg said, the machine will be checked every week and every month for the amount of radiation it delivers to patients.

The state bureau fined the center $1,000 on March 24, giving the hospital 30 days to appeal.