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

[rozental@uninet.com.br]

Dear Lam Hoi Ching



 I do believe in Hong Kong the National Authority follows the IAEA Basic

Safety Standards Recommendations, 115, 1996 – You can get your answers

looking at the Appendix II – MEDICAL EXPOSURE – Topics: Responsibilities,

Operational Considerations and Investigation of Accidental Medical

Exposures.



I would like also to recommend the IAEA-TECDOC 1113 – Safety assessment

plans for authorization and inspection of radiation sources – You can ask

to your RA, GO TO page 22 – Organizational structure, IV-1



Jose Julio Rozental

rozental@unisys.com.br  (Rio de Janeiro, until 16/02)

joseroze@netvision.net.il (Israel, after 17/02)





>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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