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'Human Error' Results in 76 CoxHealth Cancer Patients Getting too Much Radiation

By Doug Magditch

(Springfield, Mo.) -- CoxHealth gave 76 cancer patients more radiation than they needed. Equipment used to treat brain tumors and other 'difficult to treat conditions' was miscalibrated.

Wednesday, CoxHealth publicly apologized for the error, and said it will do everything it can to provide follow-up care.

The cause: human error. The chief physicist calibrated the equipment wrong when it was originally installed in 2004.

It's called the BrainLAB stereotactic radiation therapy system. It was in use at cox health between 2004 and 2009. In that time 152 patients received treatment. 76 patients received, on average, 50% more radiation than they were prescribed.

"We are extremely sorry for this error and how it has affected our patients and their families. CoxHealth takes full responsibility and is doing all we can to support and care for our patients," says Bob Bezanson, President and CEO of CoxHealth.

The health system started contacting patients February 16. So far about 70 of the 152 have been informed.

CoxHealth says the equipment is now out of service indefinitely, while its being tested.

"We'll be continuing until we're confident that the program is safe and any issues that need to be addressed have been addressed and that we've taken it up to a different level in terms of patient safety," says Dr. John Duff, Senior Vice President of Hospital Service at CoxHealth.

CoxHealth discovered the error in September. It hired a new physicist to operate the equipment. The new physicist questioned the equipment's calibration, and CoxHealth discovered it was calibrated wrong.

The Physicist who originally calibrated the equipment is no longer employed at CoxHealth.

Of the 152 patients treated by the BrainLAB equipment, 90 are now deceased. 48 of those patients were over-treated and 42 weren't. CoxHealth says it will be following the other 62 patients for the rest of their lives.

It isn't clear if any of the 76 patients that received the extra radiation have seen any side effects. Doctors say it could be years before those side effects manifest.

Current cancer patients at the Hulston Cancer Center were surprised by Wednesday's announcement. Marla Gunter, who was recently diagnosed with lung cancer, says she wouldn't want any more radiation than necessary.

"Just do what i can, what i absolutely have to do and do the best i can with it," says Gunter.

She's had some complications from her radiation treatment, but she says she'll continue it.

"You think about things like that because mistakes are made all the time. It can't be helped. You know, it happens, so, it's in the back of my mind, but, you just gotta think positive," says Gunter.

Contact: dmagditch@kspr.com

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