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RE: Medical Misadministration
Group,
I must confess that I haven't read each response in detail but there seems
to be the idea that the NRC just shrugs off a misadministration. Don't
anybody think a hospital isn't cited for a misadministration or that the NRC
doesn't put the administrative screws to the facility.
Just like any citation the response requires that the facility say 1] why it
happened, [2] what is to be done to fix the situation, [3] what is being
done to prevent reoccurrence, and [4] when the licensee will be in full
compliance. I assure you. I have been fortunate never to have been
involved in a misadministration so I can't comment too much on the details
of what happens. But an investigation by the NRC on site is common I
believe.
Perhaps one reason some mention work load and such as defenses is that there
are misadministration and misadministrations. The one reported was serious.
But having the dose be off by 20% of that prescribed is the threshold. If
that was from a 20 mCi administration of Tc-99m the medical consequences
would be fairly small for getting 24 instead of 20. Getting only 16 would
probably be worse as that study might need to be repeated if the images were
not satisfactory.
I assure you misadministrations are not taken lightly by the NRC. I assume
state agencies also take them seriously. They imposed a whole new
requirement a few years ago of a Quality Management Program for all therapy
and any I-131 administrations above 30 uCi. That program requires a
"written directive" for all such adminiatrations and dual verification of
identity, documented. Dual ID is the standard of practice throughout out
the medical community for ALL administrations but it is generally not
documented for non QMP administrations.
I personally observed one of our NM Techs prevent a misadministration of a
non-QMP procedure, asking the patient his DOB and it didn't match and then
his last four [digits of social security number] and they did not match
although the name was the same. The patient was not given the isotope, he
was in the wrong area but responded to the name. That's the way it is
supposed to work ALL THE TIME. But nothing ever does. The QMP was imposed
due to a couple dozen misadmins a year over hundreds of thousands of NM
procedures.
Any opinions expressed are mine alone and do not necessarily represent those
of the Denver VA Medical Center, The Department of Veterans Affairs, or the
U.S. Government.
Peter G. Vernig
Radiation Safety Officer, VA Medical Center, 1055 Clermont St. Denver, CO
80220, ATTN; RSO MS 115
303-399-8020 ext. 2447, peter.vernig@med.va.gov [alternate
vernig.peter@forum.va.gov] Fax 303-393-5026 [8 - 4:30 MT service] Alternate
Fax 303-377-5686
"You win some, you lose some, and some get rained out." Y. Berra
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