therapeutic I-131 dose given to wrong patient

[William V Lipton <liptonw@dteenergy.com>]

All of you medical HP's?  What's going on?

The opinions expressed are strictly mine.
It's not about dose, it's about trust.

Bill Lipton
liptonw@dteenergy.com

EVENT TEXT
+------------------------------------------------------------------------------+

| AGREEMENT STATE REPORT OF A MEDICAL MISADMINISTRATION AT HERMANN
HOSPITAL IN |
| HOUSTON, TEXAS  (ABNORMAL
OCCURRENCE)                                        |
|
|
| The following text is a portion of a facsimile received from the
Texas       |
| Department of Health Bureau of Radiation
Control:                            |
|
|
| "Incident 7492 - Texas Licensee 650 - Texas is investigating.
[Abnormal     |
| Occurrence] criteria
applies."                                               |
|
|
| "INITIAL NOTIFICATION OF THERAPY MISADMINISTRATION:  License
L00650"         |
|
|
| "Hermann Hospital herewith notifies the Agency of a Misadministration
of     |
| Radioactive Materials in a therapy
procedure."                               |
|
|
| "Specifically, approximately 27.3 mCi of I-131 was administered to the
wrong |
| patient at approximately 1040 a.m. [CDT] on August 4, 1999.  The error
was   |
| discovered at 1315 [CDT] on August 4,
1999."                                 |
|
|
| "The patients involved were both outpatients, female Oriental's,
with        |
| English as a secondary language.  Patient One (for whom the therapy
was      |
| intended) is approximately 55 years old, while Patient Two (who
received the |
| dose inadvertently) is approximately 64 years
old."                          |
|
|
| "Patient Two had completed a scheduled bone density scan and [was]
still in  |
| the Nuclear Medicine area.  At that time, she was mis-identified by
the      |
| technologist who was to administer the I-131 dose.  Patient One was
later    |
| discovered in the waiting area still needing to be dosed.  She
later         |
| received the prescribed I-131 dose and returned
home."                       |
|
|
| "The nuclear medicine physicians conferred with the Patient Two's
personal   |
| care physician and with Hermann Hospital's Risk Management Office.
The      |
| patient was finally located at about 1600 [CDT] on August 4, 1999.
The      |
| Chief Nuclear Medicine Physician, the Nuclear Pharmacy Manager and
the       |
| Radiation Safety Officer proceeded to Patient Two's Home and discussed
the   |
| event with her and her husband.  With their consent, we initiated
the        |
| administration of supersaturated Potassium Iodide (1 ml three times
per day) |
| and Furosemide (Lasix) at an initial dosage of 40 mg/day at
approximately    |
| 1720 [CDT] on August 4,
1999."                                               |
|
|
| "We are, of course, continuing our assessment of the events leading up
to    |
| this misadministration and will prepare the reports required by
TAC          |
|
289.252(f)(4)."
|
|
|
| (Call the NRC operations officer for state and licensee
contact              |
|
information.)
|
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