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Re: another medical misadministration
At 08:41 AM 2/8/00 -0600, you wrote:
>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
>| |
>|
>| |
>|
>| |
>|
>| |
>|
>| |
>+--------------------------------------------------------------------------
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>
> EVENT TEXT
>+--------------------------------------------------------------------------
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>
>| 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).
>|
>+--------------------------------------------------------------------------
----+
>
>
>
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>
Dear Radsafers:
My first comment is that 100 microcuries of I-131 for a thyroid scan is
awfully old fashioned, and has been replaced by I-123 for many years. As
long as one is not looking for substernal thyroid, one can use Tc-99m
pertechnetate also. If this was a patient who was going to get I-131 for
thyroid ablation, one could justify the 100 microcuries I-131 dose, but then
the error is irrelevant. As usual, not enough information is in the report.
My next comment is, is this a diagnostic radiology practice or one of a
board-certified nuclear medicine physician? As most of these mistakes
happen in diagnostic radiology practices, those who think that the error
rate is too high ought to look at the de facto pathetic qualifications of
many diagnostic radiologists to perform nuclear medicine thyroid imaging and
therapy.
My last comment is that an EDE of 31 rem assumes an uptake in the low 40's
or so in a normal sized gland (ICRP no. 35). This is not a normal uptake,
and sounds like a hyperthyroid gland, in which case the patient was probably
going to get a millicurie dose of I-131 anyway.
Ciao, Carol
Carol S. Marcus, Ph.D., M.D.
<csmarcus@ucla.edu>
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information can be accessed at http://www.ehs.uiuc.edu/~rad/radsafe.html