[Date Prev][Date Next][Thread Prev][Thread Next][Date Index][Thread Index]

overexposure - mother breast feeds child after I-131 therapy



HOSPITAL                          |              |EVENT NUMBER:  34618   |  
   
+----------------------------------+              +-----------------------+ 
  
  

+------------------------------------------------+-----------------------------
+ 
|LICENSEE: WESTERN PENNSYLVANIA HOSPITAL         |NOTIFICATION DATE:
08/07/98  
| 
|    CITY: PITTSBURGH             REGION: 1      |NOTIFICATION TIME: 17:03 
[ET]| 
|  COUNTY: ALLEGHENY               STATE: PA     |EVENT DATE:       
07/28/98  
| 
|LICENSE#:                     AGREEMENT: N      |EVENT TIME:        
12:00[EDT]| 
|  DOCKET:                                       |LAST UPDATE DATE: 
08/07/98  
| 
|                                                
+-----------------------------+ 
|                                                |PERSON           
ORGANIZATION| 
|                                                |TOM MOSLAK           RDO  
  
| 
|                                                |FRED COMBS, NMSS     EO   
  
| 
+------------------------------------------------+                          
  
| 
|NRC NOTIFIED BY: MILE PACILIO, RAD SAF OFF      |                          
  
| 
|HQ OPS OFFICER:  DICK JOLLIFFE                  |                          
  
| 
+------------------------------------------------+                          
  
| 
|EMERGENCY CLASS: NOT APPLICABLE                 |                          
  
| 
|10 CFR SECTION:                                 |                          
  
| 
|BAE1 20.2202(b)(1)       PERS OVEREXPOSURE      |                          
  
| 
|                                                |                          
  
| 
|                                                |                          
  
| 
|                                                |                          
  
| 
|                                                |                          
  
| 
+------------------------------------------------+-----------------------------
+ 
 
                                   EVENT TEXT 

+------------------------------------------------------------------------------
+ 
| - OVEREXPOSURE OF A 4 YEAR OLD CHILD DUE TO BREAST FEEDING BY HIS MOTHER -
  
| 
|                                                                           
  
| 
| ON 07/28/98, A 43 YEAR OLD FEMALE PATIENT REPORTED TO WESTERN PENNSYLVANIA
  
| 
| HOSPITAL TO BE EVALUATED FOR THYROID ABLATION THERAPY.  DURING
CONSULTATION  
| 
| WITH HOSPITAL PERSONNEL, THE PATIENT DENIED BREAST FEEDING HER 4 YEAR OLD 
  
| 
| SON. THE PATIENT CLEARLY HAD THE ABILITY TO SPEAK AND UNDERSTAND THE      
  
| 
| ENGLISH LANGUAGE.  A HOSPITAL RADIATION TECHNOLOGIST ADMINISTERED A 3.02  
  
| 
| MILLICURIE CAPSULE OF I-131 TO THE PATIENT IN PREPARATION FOR A WHOLE BODY
  
| 
| SCAN SCHEDULED ON 07/31/98.                                               
  
| 
|                                                                           
  
| 
| ON 07/31/98, THE PATIENT RETURNED TO THE HOSPITAL FOR A WHOLE BODY SCAN.  
  
| 
| THE PATIENT WAS COUNSELLED BY THE ATTENDING HOSPITAL PHYSICIAN AND A      
  
| 
| MEMBER OF THE HOSPITAL RADIATION SAFETY OFFICE CONCERNING THE PRECAUTIONS 
  
| 
| SURROUNDING THE IMPENDING ABLATION THERAPY SCHEDULED FOR 08/04/98.  AFTER 
  
| 
| THIS COUNSELLING, THE PATIENT ADMITTED TO BREAST FEEDING HER SON DURING   
  
| 
| THE PREVIOUS THREE DAYS, STATING THAT SHE HAD BEEN TOO EMBARRASSED TO     
  
| 
| DISCLOSE THIS DURING HER PREVIOUS HOSPITAL VISIT.  THREE HOSPITAL
EMPLOYEES  
| 
| TOLD THE PATIENT TO IMMEDIATELY DISCONTINUE BREAST FEEDING HER SON.       
  
| 
|                                                                           
  
| 
| ON 08/03/98, THE PATIENT AND HER SON RETURNED TO THE HOSPITAL IN ORDER TO 
  
| 
| HAVE ANY UPTAKE BY HER SON ASSESSED.  A BIOASSAY OF THE CHILD'S THYROID   
  
| 
| GLAND DETERMINED THAT IT HAD A BURDEN OF 2.7 MICROCURIES OF I-131, WHICH  
  
| 
| EQUATES TO AN ORGAN DOSE OF 184 RADS (TEDE = 5.5 RADS).  DURING SUBSEQUENT
  
| 
| CONVERSATIONS WITH THE PATIENT, SHE REVEALED THAT SHE HAD CONTINUED       
  
| 
| TO BREAST FEED HER SON OVER THE WEEKEND, INCLUDING IMMEDIATELY BEFORE     
  
| 
| REPORTING TO THE HOSPITAL FOR THE BIOASSAY.                               
  
| 
|                                                                           
  
| 
| HOSPITAL PERSONNEL SUSPENDED ADMINISTERING ANY ADDITIONAL I-131 TO THE    
  
| 
| PATIENT AND ARE CONTINUING TO FOLLOW THE CONDITION OF THE PATIENT AND     
  
| 
| THE CHILD.  THE HOSPITAL NUCLEAR PHYSICIAN NOTIFIED THE CHILD'S PHYSICIAN 
  
| 
| WHO IS COORDINATING FOLLOWUP CARE, INCLUDING ASSESSMENT BY A PEDIATRIC    
  
| 
| ENDOCRINOLOGIST AND PROTECTION BY THE LOCAL CHILD YOUTH SERVICES.         
  
| 
| THE HOSPITAL NUCLEAR PHYSICIAN ALSO NOTIFIED THE PATIENT'S ATTENDING      
  
| 
| PHYSICIAN AND SURGEON CONCERNING THIS INCIDENT IN ORDER TO COORDINATE     
  
| 
| THE PROTECTION OR TREATMENT ALTERNATIVES FOR THIS PATIENT.                
  
| 
|                                                                           
  
| 
| HOSPITAL PERSONNEL DO NOT PLAN TO ISSUE A PRESS RELEASE REGARDING THIS    
  
| 
| INCIDENT.                                                                 
  
| 
+------------------------------------------------------------------------------
+ 
 

************************************************************************
The RADSAFE Frequently Asked Questions list, archives and subscription
information can be accessed at http://www.ehs.uiuc.edu/~rad/radsafe.html