Re: "Oops, I did it, again." (medical misadministration)

[LAM HOI CHING <lamhc@HKUSUA.HKU.HK>]

The event was : A patient was prescribed 32 mCi of I-131,  but was

administered 120 mCi.  

 

Discussions had so far been on the dose limit of 10CFR, but I would think

it rather be a mistake in the procedure of handling.



I know that for a busy RT department,  many thyrotoxicosis patients and

ablation patients may be treated at the same time. If the dose activities

of the oral I131 are all different, without the proper labelling of the

activity, then mistakes will not be avoided.



There are the following questions:

1. Who was responsible to give the dose to the patient ? Physician or

radiographer ?

2. Should the person measure the activity of the I131, liquid or capsule

form with the dose calibrator.

3. Are there any labelling on the prescription dose in mCi and the

corresponding name-tag on that dose vial or capsule pot.

4. Is there any procedure for the operator to read the patient name

information and drug information and ask that present name before

prescribing that oral dose to him.

5. Verify and validate the dose and patient matching !!

5. Again it is a matter of normal procedure running rather than the dose



John Lam, Physicist, Eastern Hospital, Hong Kong



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