[ RadSafe ] Medical Incident

Perle, Sandy sperle at mirion.com
Fri Aug 30 10:23:29 CDT 2013

Completely agree with you Bill. Absolutely no excuse. There should be a penalty and the Technologist should be reprimanded.  


Sandy Perle
Sent from my iPhone

On Aug 30, 2013, at 8:14 AM, "William Lipton" <doctorbill34 at gmail.com> wrote:

> 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.
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