Date: August 2000-24 March 2001
Location: Instituto Oncologico Nacional, Panama City, Panama
Type of event: radiotherapy accident
Description:
In August 2000 a modification to the computerized treatment planning system used to calculate shielding blocks during radiotherapy treatments. Unknown to the operators, the change resulted in overexposures to patients. Development of symptoms in treated patients led to discovery of the error on 24 March 2001, after 28 patients had been overexposed. Five patients died due to overexposure, one died in December 2000 of cancer unrelated to treatment, and two died by 2001 (one on 19 October 2000, 2 weeks after treatment) of undetermined causes. Of the radiation-related deaths, dates were as follows: 6 March, about 3 weeks after treatment; 28 March, about 7 weeks after treatment; 7 May, about 13 weeks after treatment; 19 May, about 10 weeks after treatment; 20 May, about 12 weeks after treatment; Most of the other 20 patients displayed injuries, mostly involving radiation injury to the bowel. By 23 May 2002, 17 patients had died, with 13 of the deaths caused by rectal complications and 14 deaths total linked to radiation exposure. By August 2003, 21 patients total had died with 17 of the deaths attributed to radiation exposure. For all deaths, times between exposure and death were 35, 47, 69, 115, 116, 117, 172, 277, 292, 292, 319, 321, 326, 345, 363, 386, 439, 650, 691, 782, and 836 days.
Consequences: 17 deaths, 11 injuries.
References:
© 2004 by Wm. Robert Johnston.
Last modified 21 June 2004.
Return to Home. Return to Nuclear Weapons Resources. Return to Database of radiological incidents and related events.