[ RadSafe ] Fwd: Medical Incident

[Siegel, Barry]

Incidents such as this need to be reported to the NRC when they meet the criteria of a medical event (see http://www.nrc.gov/reading-rm/doc-collections/cfr/part035/part035-3045.html).

With 37.4 mCi Tc-99m DTPA given IV, the EDE = 1.12 rem and the critical organ dose (urinary bladder) =10.47 rad (with both based on a very conservative voiding interval of 4,8 hours after injection).  These are about 1/5th of the threshold for reporting.

Radiopharmaceutical incidents certainly should be minimized, but the available data actually suggest they are far less frequent than "misadministrations" of non-radioactive drugs, which in general are far more likely to lead to actual harm.

Barry A. Siegel, MD
Former chair, NRC Advisory Committee on Medical Uses of Isotopes (ACMUI)
siegelb at mir.wustl.edu

-----Original Message-----
From: radsafe-bounces at health.phys.iit.edu [mailto:radsafe-bounces at health.phys.iit.edu] On Behalf Of Chris Alston
Sent: Friday, August 30, 2013 3:39 PM
To: The International Radiation Protection (Health Physics) Mailing List
Subject: [ RadSafe ] Fwd: Medical Incident

Joey

It did likely not meet the regulatory thresholds (I have not done the math).  Some folks feel that they are being good citizens, by reporting such medication errors directly and immediately to the regulatory agents, rather than reporting indirectly, via the inevitable discussions in, for instance, the RSO's quarterly reports, and the minutes of the Radiation Safety Committee.  Other folks simply don't understand the rules.

Cheers
cja
---------- Forwarded message ----------
From: Michael, Joey L <joey-michael at uiowa.edu>
Date: Fri, Aug 30, 2013 at 4:06 PM
Subject: Re: [ RadSafe ] Medical Incident
To: "The International Radiation Protection (Health Physics) Mailing List" <radsafe at agni.phys.iit.edu> 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.
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