[ RadSafe ] Medical Incident

William Lipton doctorbill34 at gmail.com
Fri Aug 30 10:13:54 CDT 2013

The following is from today's (Aug. 30) NRC Event Reports:

The following was received from the State of Oregon via facsimile:

"The inpatient was having an Adenosine Myoview stress test. The Nuclear
Medicine Technologist took the dose that was already in the dose calibrator
(place there earlier by another Nuclear Medicine Technologist). It measured
about the same activity as 99m-Tc Myoview would measure in the dose
calibrator. The Nuclear Medicine Technologist gave the patient 37.4
millicuries of 99m-Tc DTPA (lung ventilation dose) instead of 30
millicuries of 99m-Tc Myoview. The route of administration for 99m-Tc DTPA
is inhalation and the route of administration for 99m-Tc Myoview is
intravenous. The 99m-Tc DTPA was intended for a different patient. The
patient was informed of the mistake and the stress test will be repeated
tomorrow (8/22/13). The ordering physician was also notified of the event.
There were no adverse effects to the patient, just delayed the study.

"This will be reported at the next Radiation Safety Committee Meeting along
with any actions that will be taken to prevent this in the future."*
Fortunately, the patient wasn't harmed, other than having to undergo a
repeat test.

What bother's me is:   (1) the frequency of this type of event, and (2) the
lack of any meaningful NRC penalty.  There's no excuse for treating the
wrong patient.  Can these folks even spell "QA"?  The NRC seems to have a
double standard, with medical licensees getting a slap on the wrist for
incidents which would hit a power reactor with a minimum Level 3 violation.
 What's even worse:  The only reason this was reported is that it involved
a NRC license.  What else goes on that we never hear about?

Bill Lipton
It's not about dose, it's about trust.

More information about the RadSafe mailing list