[ RadSafe ] Medical Incident

Wed Sep 4 19:57:57 CDT 2013

Just like the most rudimentary QA program should have prevented the exposure of 8 patients to prions.

Eight patients monitored for deadly Creutzfeldt-Jakob brain disease, N.H. says 

http://www.cnn.com/2013/09/04/health/new-hampshire-cjd/index.html?sr=sharebar_twitter

Unfortunately, not everything will ever be perfect. We can strive for it but perfection will never be achieved.

It would be ludicrous to shut down all hospitals until they figure out how to prevent MRSA exposure, surgeries on the wrong limb, and exposure to prions. We realize the good outweighs the bad. 

Risk vs Reward not improper leniency from regulators. 

Jeff

On Sep 4, 2013, at 10:28 AM, William Lipton <doctorbill34 at gmail.com> wrote:

> This was an egregious error, regardless of the dose consequences,
> reportability, or semantics.  Even the most rudimentary QA program would
> have prevented this.
> 
> For power reactors, NRC violations are based on potential as well as actual
> consequences, i.e., "loss of control."   I hope that you folks appreciate
> the leniency you receive from the regulators.
> 
> Bill Lipton
> It's not about dose, it's about trust.
> On Sep 4, 2013 10:26 AM, "Kent Lambert" <kent.lambert at drexel.edu> wrote:
> 
>> 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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>> 
>> 
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