[ RadSafe ] Medical Incident

Michael, Joey L joey-michael at uiowa.edu
Fri Aug 30 15:06:53 CDT 2013

An NRC reportable medical event has to result in an effective dose equivalent of 5 rem or 50 rem to an organ.  Most diagnostic procedures will not meet this threshold.  It is not clear that the event below met the requirements to be reported.


-----Original Message-----
From: radsafe-bounces at agni.phys.iit.edu [mailto:radsafe-bounces at agni.phys.iit.edu] On Behalf Of William Lipton
Sent: Friday, August 30, 2013 10:14 AM
To: radsafe
Subject: [ RadSafe ] Medical Incident

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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