[ RadSafe ] Medical Incident

Stroud - CDPHE, Ed ed.stroud at state.co.us
Tue Sep 3 07:47:02 CDT 2013

Oregon is an Agreement State, so they have their own licensing and
inspection program. NRC would not be involved. If such an incident happened
here in Colorado, also an Agreement State, we would do the investigation
and issue the NOV (Notice of Violation) or penalties deemed necessary.

Ed Stroud, Compliance Lead
Radioactive Materials Unit
Colorado Department of Public Health and Environment

On Fri, Aug 30, 2013 at 9:13 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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