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medical misadministration to child
Please see the NRC event report that I pasted, below. A 9 year old
patient who was in for a thyroid diagnostic scan was supposed to receive
4 uCi. Instead, he (she) received 400 uCi. The cause is stated as,
"The wrong dosage was ordered from the radiopharmacy." It seems as if
the dose rate should have warned them that something was wrong.
I'm curious about the statement, "The hospital indicated they did not
expect any significant adverse health effect." Table E-13, of NRC
Regulatory Guide 1.109, "Calculation of Annual Doses to Man From Routine
Releases of Reactor Effluents ..." lists a dose factor, for a child
thyroid for I-131 ingestion, of 5.72 E-3 mrem/pCi ingested.
Thus, the dose estimate would be:
(5.72 E-3 mrem/pCi)*(400 uCi)*(1 E6 pCi/uCi) = 2.3 E6 mrems = 2300 rems
The nonstochastic occupational limit for a minor would be 5 rems. It
seems like the patient could expect a "significant adverse" health
effect.
The opinions expressed are strictly mine.
It's not about dose, it's about trust.
Curies forever.
Bill Lipton
liptonw@dteenergy.com
Hospital |Event Number:
39725 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: DEACONESS HOSPITAL |NOTIFICATION DATE:
04/03/2003|
|LICENSEE: DEACONESS HOSPITAL |NOTIFICATION TIME:
16:35[EST]|
| CITY: EVANSVILLE REGION: 3 |EVENT DATE:
03/28/2003|
| COUNTY: STATE: IN |EVENT TIME:
11:00[CST]|
|LICENSE#: 13-00142-02 AGREEMENT: N |LAST UPDATE DATE:
04/03/2003|
| DOCKET:
|+----------------------------+
| |PERSON
ORGANIZATION |
| |BRENT CLAYTON
R3 |
| |TRISH HOLAHAN
NMSS |
+------------------------------------------------+
|
| NRC NOTIFIED BY: DENISE BEAN
| |
| HQ OPS OFFICER: RICH LAURA
| |
+------------------------------------------------+
|
|EMERGENCY CLASS: NON EMERGENCY
| |
|10 CFR SECTION:
| |
|LDIF 35.3045(a)(1) DOSE <> PRESCRIBED
DOSA| |
|
| |
|
| |
|
| |
|
| |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| MEDICAL EVENT AT DEACONESS HOSPITAL IN
INDIANA |
|
|
| A medical event occurred on 3/28/03 at 11:00 CST when a 9 year old
patient |
| received an actual dose of 400 microcuries of I-131, for a thyroid
scan and |
| uptake, instead of a planned dose of 4 microcuries of I-131. The
error |
| occurred when the patient couldn't swallow the capsule and the
hospital |
| ordered a liquid form of the radioisotope. The wrong dosage was
ordered |
| from the radiopharmacy. The error was not discovered until after the
dosage |
| had been administered. The hospital indicated they did not expect
any |
| significant adverse health effect. The hospital was performing some
more |
| detailed calculations involving this event. A review was initiated
to |
| clearly identify the cause and initiate corrective actions to
prevent |
|
recurrence.
|
************************************************************************
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