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Medical Event
The attached description of a medical event, taken from the February 2,
2004, NRC Daily Events Report, describes a misadministration, in which a
patient who had been prescribed 5 uCi of I-131 was actually given 500
uCi. This seems particularly egregious since the administration was
given on the basis of a verbal order. Those administering the
radionuclide should have been aware of the provisions of 10 CFR
35.40(a), or equivalent MA regulations, that require a written directive
for administering > 30 uCi of I-131. I hope that the corrective actions
include an upgrading of the hospital's Quality Assurance program, and
that the lessons learned are shared with the industry, to prevent
recurrences.
I have one other comment:
NCRP Report No. 65, "Management of Persons Accidently Contaminated With
Radionuclides," states (page 86) that for accidental exposures to
radioiodine, "Daily administration of 300 mg KI should be continued for
7 to 14 days. The continuation of the blocking agent is needed to
prevent recycling of the radioiodine..." The event report states that
the patient was given a blocking agent, but does not say anything about
continuing administration. Has this been done?
Hospital Event Number: 40490
Rep Org: US DEPT OF VETERANS AFFAIRS
Licensee: VA BOSTON HEALTHCARE SYSTEM
Region: 1
City: BOSTON State: MA
County:
License #: 03-23853-01VA
Agreement: Y
Docket:
NRC Notified By: GARY WILLIAMS
HQ OPS Officer: STEVE SANDIN Notification Date: 01/30/2004
Notification Time: 13:26 [ET]
Event Date: 01/30/2004
Event Time: 11:51 [EST]
Last Update Date: 01/30/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
PATRICK LOUDEN (R3)
GLENN MEYER (R1)
TRISH HOLAHAN (NMSS)
Event Text
MEDICAL EVENT DUE TO ADMINISTERED DOSE EXCEEDING PRESCRIBED DOSAGE TO
THE THYROID
"The medical event occurred at a medical broad-scope permittee
authorized under the master materials license issued to the Department
of Veterans Affairs, NRC License 03-23853-01VA. The permittee is VA
Boston Healthcare System, Boston, Massachusetts.
"The medical event occurred on January 29, 2004, and was discovered the
same day.
"The basis for the medical event is under 10 CFR 35.3045(a)(1)(ii) in
that an administered dosage differed from the prescribed dosage by more
than 20% and resulted in a dose of more than 50 rem to an organ.
"Specifically, the verbal order from the authorized user was for 5
microcuries Iodine 131 and the patient was given 500 microcuries Iodine
131. After the event was discovered, the patient was given a thyroid
blocking solution. Based on the patient's resultant thyroid uptake, the
permittee computed a dose to the thyroid of approximately 83 rem.
"The authorized user does not anticipate any adverse medical effects to
the patient.
"The permittee has implemented initial corrective actions to prevent a
recurrence of the circumstances that resulted in the medical event.
"The Department of Veterans Affairs will evaluate the circumstances
related to the medical event and submit a written report to NRC, Region
III, within 15 days."
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