Radioisotope misadministrations

["J. J. Rozental" <josrozen@netmedia.net.il>]

Whether  a misadministration  can be  acceptable or not (to somebody)
depends on the balance of causes and consequences... Decision is influenced
by the same factors. Taking into account the definition of Abnormal
Occurrence (AO) by NRC, I fully agree with the Regulatory Authority. It is
the responsibility of the licensee to take all reasonable measures to
prevent failures and errors, including the selection of suitably qualified
personnel, the establishment of adequate procedures for the calibration,
quality assurance and operation of diagnostic and therapeutic equipment, and
the provision to personnel of appropriate training and periodic retraining
in the procedures. In one or more than one of such responsibilities the
licensees failed both in Nuclear Medicine and Radiotherapy


The seven cases in Nuclear Medicine are the following:
http://www.nrc.gov/NRC/COMMISSION/SECYS/1997-023scy.html

1)  Radiopharmaceutical Misadministration  Administering a
radiopharmaceutical other than the one intended, where the actual dose is
greater than five times the prescribed dose.
 
 2) Radiopharmaceutical Misadministration  -  An actual diagnostic dose of a
radiopharmaceutical is greater than five times the prescribed dose.

3)  Radiopharmaceutical Misadministration  - An actual diagnostic dose of a
radiopharmaceutical is greater than five times the prescribed dose.


4) Radiopharmaceutical Misadministration  - A therapeutic dose such that the
actual dose is less than 0.5 times the prescribed dose.

5) Radiopharmaceutical Misadministration  - A therapeutic dose of a
radiopharmaceutical differing from the prescribed dose by more than 10
percent, and the actual dose is less than 0.5 times the  prescribed dose. 

6) Radiopharmaceutical Misadministration - Administering a diagnostic dose
of a radiopharmaceutical  differing from the prescribed dose by more than 50
percent, and the actual dose is greater than five times the prescribed dose.

7)  Radiopharmaceutical Misadministration  - Administering a therapeutic
dose such that the actual dose is less than 0.5 times the prescribed dose. 

J. J. Rozental
josrozen@netmedia.net.il
Israel




jjrozental

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