medical misadmisintration - PN Report

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

Here's the NRC, "Preliminary Notification" report.  One question:  If
the misadministration was discovered at 10:40 A.M., why did they wait
until 4:00 P.M. to be "dispatched to the Patient B's home" to administer
the blocking agen?  The 5- 6 hour delay probably had a significant
impact on the dose to Patient B. For example, NCRP Report No. 65,
"Management of Persons Accidentally Contaminated with Radionuclides,"
states (section 7.3.4.2):  "... One blocking dose of 300 mg of iodide,
if given within 30 minutes, will stop further uptake of radioiodine by
the thyroid.   Only about 50 percent of the uptake is blocked if the
iodide administration is delayed six  hours ..."   NCRP 65 also states
(section 6.8):  "Daily administration of 300 mg KI should be continued
for 7 to 14 days.  This continuation of the blocking agent is needed to
prevent recycling of the radioiodine ..."  Has this followup care been
given?

Please don't tell me they were too busy.  Oh well, the thyroid is highly
overrated, anyway.

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

Bill Lipton
liptonw@dteenergy.com

August  9, 1999

PRELIMINARY NOTIFICATION OF EVENT OR UNUSUAL OCCURRENCE PNO-IV-99-034

This preliminary notification constitutes EARLY notice of events of
POSSIBLE
safety or public interest significance. The information is as initially
received without verification or evaluation, and is basically all that
is
known by Region IV staff in Arlington, Texas on this date.

Facility                                    Licensee Emergency
Classification
State Of Texas Licensee                       Notification of Unusual
Event
Hermann Hospital                                 Alert
Houston,Texas  77030-1501                Site Area Emergency
License No: L00650                             General Emergency
                                                              X Not
Applicable

Subject:  MEDICAL MISADMINISTRATION INVOLVING IODINE-131

On August 5, 1999, the Radiation Safety Officer for Hermann Hospital (a
State of Texas
licensee) located in Houston, Texas, provided written notification to
the Texas Department of
Health, Bureau of Radiation Control (BRC) of a medical misadministration
involving the
administration of 1.01 gigabecquerels (27.3 millicuries) of iodine-131
(I-131) to the wrong
patient.

The licensee reported that two female out-patients (both with English as
their secondary
language) were involved in the error which occurred on the morning of
August 4, 1999.
Patient A (for whom the therapeutic dose of I-131 was intended) was
approximately 55 years
old while Patient B (who inadvertently received the I-131 dose) was
approximately 64 years
old. Patient B had completed a scheduled bone density scan and was still
in the nuclear
medicine department. At that time, she was misidentified by the
technologist as the patient
who was to receive a therapeutic dose of I-131. She was then
administered 1.01
gigabecquerels of I-131 at approximately 10:40 a.m. (CDT) and was sent
home. Patient A was
later observed to still be in the waiting room needing to be
administered the I-131. At this time,
the licensee realized that the misadministration occurred. Patient A was
then administered the
prescribed dose of I-131 and returned home.

At approximately 4:00 p.m. (CDT) on August 4, 1999, the Radiation Safety
Officer, the Chief of
the Nuclear Medicine Department and the Nuclear Pharmacy Manager were
dispatched to
Patient B's home to discuss the misadministration with her and her
husband. With the
patient's consent, the Nuclear Medicine Physician initiated the
administration of
supersaturated Potassium Iodide (1 milliliter three times per day) and
Furosemide (Lasix) at
an initial dose of 40 milligrams per day to reduce the patient's
radiation exposure caused by
the error. The administrations were completed at approximately 5:20 p.m.
(CDT).

The BRC is currently investigating the misadministration.

RIV received notification of this occurrence by facsimile from TDH on
August 6, 1999.

Region IV has informed OSP and NMSS.

 This information has been discussed with BRC and is current as of 11:00
a.m. on August 9,
1999.



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