nuclear medicine misadministration

[William V Lipton <liptonw@DTEENERGY.COM>]

In the "What were they thinking?" department, see the attached

notification from today's (June 3, 2003) NRC Daily Event Report.  A

patient who was supposed to be administered 5 mCi of I-131, was

administered 27 mCi.  Apparently, the technician involved accurately

assayed the dose as 27 mCi, and noted that it differed from the

prescribed dose, but administered the material to the patient anyway.

Can those folks even spell, "QA"?



Please don't reply that no one was hurt, so it's no big deal.  There's a

lot of evidence of the unacceptably high proportion of patients who are

hurt thru hospital errors.  This is just one indication.



The opinions expressed are strictly mine.

It's not about dose, it's about trust.

Curies forever.



Bill Lipton

liptonw@dteenergy.com





AGREEMENT STATE REPORT -

ARIZONA                                             |

|

|

| The following information was obtained from the Arizona Radiation

Regulatory |

| Agency via

facsimile:                                                        |

|

|

| "On May 27, 2003, a patient was administered 27 mCi of Iodine-131

(Iodide)   |

| instead of the prescribed dose of 5 mCi. Initial investigation

indicates     |

| that Medi-Physics Inc. had mistakenly sent a 27 mCi dose designated

for AMI  |

| to Phoenix Baptist Hospital and the 5 mCi dose for Phoenix Baptist

Hospital  |

| to AMI.  It appears that the 27 mCi dose had been accurately assayed

by the  |

| Technician, had been noted to differ from the requested 5 mCi, but had

been  |

| administered to the patient anyway.  It should also be noted that

the        |

| patient had a thyroid ablation procedure conducted previously.

Medi-Physics |

| Inc. and Phoenix Baptist Hospital are investigating the situation and

a      |

| report from each will be

forthcoming.                                        |

|

|

| "The Agency and licensees will continue to investigate this occurrence

and   |

| report

further."                                                             |





************************************************************************

You are currently subscribed to the Radsafe mailing list. To unsubscribe,

send an e-mail to Majordomo@list.vanderbilt.edu  Put the text "unsubscribe

radsafe" (no quote marks) in the body of the e-mail, with no subject line.

You can view the Radsafe archives at http://www.vanderbilt.edu/radsafe/