[Date Prev][Date Next][Thread Prev][Thread Next][Date Index][Thread Index]
another medical misadministration
The following is taken from the NRC Daily Events Report of February 8,
2000. I am concerned about the frequency of these events. In this
case, I am even more concerned the length of time that will apparently
elapse between the misadministration and the needed intervention. The
event time is stated as 0900 CST. The notification time is stated as
1714 EST = 1614 CST. Thus, 7.25 hours elapsed between the event and the
notification. At the time of the notification, they had contacted the
patient, but had not yet administered the KI. NCRP 65, "Management of
Persons Accidentally Contaminated with Radionuclides," (page 138)
states, "...Only about 50 percent of the uptake is blocked if the iodide
administration is delay six hours and little effect can be achieved if
the delay is more than 12 hours... If stable iodied is given after the
first 24 hours, it may sometimes prolong the retention of iodine, since
it suppressses the release of thyroid hormone..." In addition, the
report (page 86) recommends that daily KI administration continue for
7-14 days to prevent recycling.
Oh well, I hear that the thyroid is highly overrated!
The opinions expressed are strictly mine.
It's not about dose, it's about trust.
Bill Lipton
liptonw@dteenergy.com
Hospital |Event Number:
36668 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: ST. ANTHONY MEDICAL CENTER |NOTIFICATION DATE:
02/07/2000|
|LICENSEE: ST. ANTHONY MEDICAL CENTER |NOTIFICATION TIME:
17:14[EST]|
| CITY: CROWN POINT REGION: 3 |EVENT DATE:
02/07/2000|
| COUNTY: STATE: IN |EVENT TIME:
09:00[CST]|
|LICENSE#: 13-15933-01 AGREEMENT: N |LAST UPDATE DATE:
02/07/2000|
| DOCKET:
|+----------------------------+
| |PERSON
ORGANIZATION |
| |MICHAEL PARKER
R3 |
| |JOE HOLONICH
NMSS |
+------------------------------------------------+
|
| NRC NOTIFIED BY: RAM BASAVATIA
| |
| HQ OPS OFFICER: BOB STRANSKY
| |
+------------------------------------------------+
|
|EMERGENCY CLASS: N/A
| |
|10 CFR SECTION:
| |
|LADM 35.33(a) MED MISADMINISTRATION
| |
|
| |
|
| |
|
| |
|
| |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| MEDICAL
MISADMINISTRATION |
|
|
| A patient, who was prescribed a dose of 100 µCi I-131 for a thyroid
scan, |
| was administered a dose of 500 µCi I-131. The patient was released
before |
| the error was discovered. The patient has since been contacted and
is |
| returning to the hospital to be administered KI (potassium iodide) to
limit |
| the uptake of radioiodine in the thyroid. The licensee radiation
safety |
| officer did not provide an estimate of the thyroid dose, but stated
that |
| whole body dose would be approximately 31 rads without administration
of |
|
KI.
|
|
|
| The patient's attending physician will be informed of
this |
| misadministration. The licensee has already contacted NRC Region III
(T. |
|
Go).
|
+------------------------------------------------------------------------------+
************************************************************************
The RADSAFE Frequently Asked Questions list, archives and subscription
information can be accessed at http://www.ehs.uiuc.edu/~rad/radsafe.html