A patient was the victim of a laterality error (right-left inversion) in the treatment of her breast cancer. The facts were revealed by the nuclear safety authority (ASN), which explains that they took place at the greater Montpellier cancer center.
The error “occurred during treatment preparation, during the selection of the target organ at the delineation stage. The subsequent stages, including various validations during the preparation of the treatment and then its execution, did not make it possible to identify this error,” recalls the nuclear safety authority, informed on March 25. “Eight treatment sessions out of the twenty-five planned were thus carried out on the wrong side. The error was detected during a weekly follow-up consultation, due to the appearance of side effects on the side opposite to that of the tumor. »
ASN “notes the increase in this type of error”. He calls “the attention of radiotherapy professionals to the need to evaluate the robustness of the safety barriers put in place to protect against laterality errors”. A similar case occurred at the same time in Dijon, at the Burgundy cancer institute. The entire treatment was performed on the patient’s wrong breast.