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"Oops, I did it, again." (medical misadministration)
Again, with my apologies to Britney, I refer you to yet another medical
misadmistration, as reported in the NRC daily, "Event Notification
Report." PNO-IV-02-030, available from ADAMS, includes similar
information. A patient was prescribed 32 mCi of I-131, but was
administered 120 mCi. The report notes that, "As patient's thyroid was
to be ablated anyway, no ill |
| effects to patient." However, it does not report how the increased
external dose was managed. The Rad Health Handbook (1970 edition) gives
a dose factor of 2.2 R-cm2/hr-mCi for I-131. Assuming a thyroid uptake
of 30%, this works out to a dose rate of more than 85 mR/hr at 1 foot.
Since the patient was probably being treated for a hyperthyroid
condition, the uptake and dose rate are probably a lot higher - a
walking hi rad area!
My question: Was the patient released, in accordance with 10 CFR 35.75,
on the basis of a 32 mCi administration? If so, the 500 mrem exposure
limit for a member of the public was probably exceeded.
I find it hard to believe that physicians continue to complaine about
the provisions of 10 CFR 35, while incidents such as this continue to
occur.
The opinions expressed are strictly mine.
It's not about dose, it's about trust.
Curies forever.
Bill Lipton
liptonw@dteenergy.com
----------------------------------------------------------------------------+
| REP ORG: CALIFORNIA RADIATION CONTROL PRGM |NOTIFICATION DATE:
06/10/2002|
|LICENSEE: UCLA HARBOR MEDICAL CENTER |NOTIFICATION TIME:
12:40[EDT]|
| CITY: REGION: 4 |EVENT DATE:
06/10/2002|
| COUNTY: LOS ANGELAS STATE: CA |EVENT
TIME: [PDT]|
|LICENSE#: 0359-19 AGREEMENT: Y |LAST UPDATE DATE:
06/10/2002|
| DOCKET:
|+----------------------------+
| |PERSON
ORGANIZATION |
| |ANTHONY GODY
R4 |
| |FRED BROWN
NMSS |
+------------------------------------------------+
|
| NRC NOTIFIED BY: ROBERT GREGER
| |
| HQ OPS OFFICER: RICH LAURA
| |
+------------------------------------------------+
|
|EMERGENCY CLASS: NON EMERGENCY
| |
|10 CFR SECTION:
| |
|NAGR AGREEMENT STATE
| |
|
| |
|
| |
|
| |
|
| |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| AGREEMENT STATE REPORT OF MEDICAL
MISADMINISTRATION |
|
|
| "Patient who was suppose to receive 32 millicuries I-131 was given
120 |
| millicuries I-131. As patient's thyroid was to be ablated anyway, no
ill |
| effects to patient. The doctor gave her the wrong
dose." |
|
|
| The cause of the misadministration is being reviewed at the time of
the |
|
report.
|
+------------------------------------------------------------------------------+
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