For twelve years, between 2012 and 2024, a defect in configuration on a radiology apparatus of the Yves Le Foll hospital center, in Saint-Brieuc, went unnoticed. Result: 667 patients, including 4,51 children, were exposed to doses of X -ray higher than those usually delivered during this type of examination. This is the observation drawn up by the Nuclear and Radiation Protection Authority (ASNR) in a public report in early September. But with what risks?
An error spotted by chance
The error was spotted on December 2, 2024, when a radiologist notes as well as an eight -year -old child received an “unusually large” dose during an urethra radiography. The hospital alerts its management and then the ASNR, which then highlights a persistent dysfunction for twelve years. The incriminated machine delivered continuous radiation (“continuous radioscopy”) instead of a pulsed mode, normally used to limit the absorbed dose.
“Concretely, explains Dr. Gérald Kierzek, emergency doctor, When pressing the button, the X -rays are emitted. When you relax, it stops. However, the machine remained on a continuous emission, exposing the patients to a much higher irradiation “.
How is this error possible?
Technical dysfunction has remained unnoticed for years, because there was no automatic dose monitoring system before 2016. In addition to this configuration error, ASNR also points to an insufficient approach to optimizing practices and a lack of training of teams, in a context of high staff rotation. A cocktail of organizational imperfections that allowed the error to continue.
The error highlighted in December 2024 was immediately reported to the ASNR, which required a retroactive audit of all the patients exposed on this machine. The families concerned were informed, and a reconstruction of the doses could be carried out when the data were available, that is to say since 2016.
What risks for patients, especially children?
But the real question remains of course, at what risks were these children exposed? In theory, the overexposure to X -rays increases the risk of long -term cancer, because it is an ionizing radiation capable of damaging cellular DNA. However, the Dosimetric Reconstitutions carried out since 2016 allow the health impact to be put into perspective. “”The doses received remain in the category of low doses, Assures Dr. Kierzek. They do not lead to an immediate consequence or visible acute effects “.
A doubt remains on the long -term effects. “”In children, this vigilance is all the more crucial: each exhibition added throughout life. Even if the risk remains low, it is not zero “continues the doctor.
Should families worry?
Faced with this observation, families are inevitably worried. Like Anne-Claire, mother of Léon, 4, at the microphone by Armorique. His son underwent “at least five radios” from his first year, for an intestinal malformation. “When we are told after the fact that the doses were stronger than expected, we necessarily wonder what impacts it will later be” ” she says.
However, health authorities want to be reassuring: the long -term risk is qualified as “low to very low” compared to the general population. The hospital has since corrected the dysfunction, informed families and strengthened its control protocols.
“Incidents like this are extremely rare, insists Dr. Kierzek. Today, radiation protection is strictly framed “ ::
- The doses are automatically recorded in the reports;
- Modern devices radiate much less than before;
- Professionals are equipped with regularly monitored dosimeters.
The right attitude in the face of radiological examinations
But for the doctor, this case remains a good reminder for patients and parents: do not give in to the temptation of “comfort” exams. “We do not ask for a radio or a scanner to be reassured, recalls the doctor. They are only practiced when they are medically justified. Each X -ray counts, especially for children. “