Date: 10-20 December 1990

Location: Zaragoza Clinical University, Zaragoza, Spain

Type of event: radiotherapy accident

Description:

An error occurred in the maintenance and calibration of a linear accelerator used for clinical radiotherapy; combined with procedural violations, overdosages of 200-700% occurred. The accelerator is related to the Therac-25 involved in several accidents in the United States and Canada. A total of 27 patients were overexposed during treatments for tumors between 10 and 20 December. Signs of radiation injury were observed on 26 December, and the first death occurred possibly shortly thereafter. By 28 February 1991 three patients had died, and an additional 7 died by 31 March 1991. Spainish authorities were reportly hesitant to release details of the accident, but sought foreign assistance in early 1991. A total of 18 eventually died as a result of radiation overexposures. The remaining patients all suffered major disabilities as a result.

Consequences: 18 fatalities, 9 injuries.

References:

• Cosset, Jean Marc, 2002, "ESTRO Breur Gold Medal Award Lecture 2001: Irradiation accidents--lessons for oncology?," Radiotherapy and Oncology, 63:1-10.
• Miller, Vandy L., Jan. 1992, "SP-92-011, January 1992, Incid/Event, Report of an accident--Zaragoza Univer," on line at ORNL [http://www.hsrd.ornl.gov/nrc/agstates/incident/sp92011.pdf].
• Novotny, Joseph, Johanna Izewska, Andree Dutreix, and Emmanuel van der Schueren, 1998, "A quality assurance network in central European countries," Acta Oncologica, 37:159-165, on line at Taylor and Francis [http://taylorandfrancis.metapress.com/media/2724FR9EFN2QVM9EPV5M/Contributions/C/G/A/4/CGA4Q06XBUX8P00C.pdf when accessed].
• Ortiz, P., M. Oresegun, and J. Wheatley, 2000, "Lessons from major radiation accidents," on line, Internationl Radiation Protection Association [http://www.irpa.net/irpa10/cdrom/00140.pdf].
• Turai, Istvan, and Katalin Veress, 2001, "Radiation accidents: Occurrence, types, consequences, medical management, and the lessons to be learned," Central European Journal of Occupational and Environmental Medicine, 7:3-14, on line at CEJOEM [http://www.fjokk.hu/cejoem/files/Volume7/Vol7No1/CE01_1-01.html].
• WISE, 10 May 1991, "In brief," WISE News Communique, on line at WISE [http://www.antenna.nl/wise/351/brief.html].
• WISE, 10 May 1991, "In brief," WISE News Communique, on line at WISE [http://www.antenna.nl/wise/352/brief.html].

© 2004, 2005, 2008 by Wm. Robert Johnston.
Last modified 26 October 2008.
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