[ RadSafe ] Medical Incident

[Kent Lambert]

Bill,

The wrong patient was not treated, a patient was given the wrong
radiopharmaceutical.  Also, is the frequency of medical mistakes involving
the administration of radiopharmaceuticals more or less frequent than the
frequency of mistakes involving non-radioactive drugs?  Hypothetically
speaking, I would be much more worried about accidentally getting a
penicillin based antibiotic (to which I am allergic).  The consequences in
this case could be fatal (as opposed to a theoretical slight increase in the
cancer risk), but there are no regulatory consequences.  
 
It is not clear to me that this was even a reportable medical event.  I do
not know Oregon state regulations, but 10 CFR 35.3045(a)(2) requires
reporting of any event in which the administration of a radiopharmaceutical
results in a EDE >50 mSv or an organ/tissue dose of 0.5 Sv from an
administration of a wrong radioactive drug, an administration by the wrong
route of administration, or administration to the wrong individual.  The EDE
from injection of 37.4 mCi of Tc-99m  DTPA is estimated at 11 mSv and the
most exposed organ, the urinary bladder, receives an estimated dose
equivalent of 0.1 Sv.  

If a nuclear power reactor employee walked into a room only to learn later
that there was airborne radioactive contamination and the employee received
an estimated EDE of 10 mSv and the maximum organ dose was 0.1 Sv (both below
the limits in 10 CFR 20) there would be no basis for a level 3 violation.  


Kent Lambert, M.S., CHP
Director, Radiation Safety
Drexel University

1601 Cherry Street, Suite 10444
Philadelphia, PA  19102

e-mail:  kent.lambert at drexel.edu
voice:   215-255-7860
fax:     215-255-7874

-----Original Message-----
From: Stroud - CDPHE, Ed [mailto:ed.stroud at state.co.us] 
Sent: Tuesday, September 03, 2013 8:47 AM
To: The International Radiation Protection (Health Physics) Mailing List
Subject: Re: [ RadSafe ] Medical Incident

Bill,
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:
>
> *AGREEMENT STATE REPORT - PATIENT GIVEN DOSE PRESCRIBED FOR ANOTHER 
> PATIENT
> *
> *
> 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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