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Re: medical misadministration of I-131



carol marcus wrote:

> Therapy misadministrations in Nuclear Medicine are rare; several a year with
> roughly 60,000 or so therapy administrations.  For comparison, the number of
> nonradioactive drug mistakes in hospitals is 10-30 PER CENT of drug
> administrations, and many of these cause deaths or severe morbidity.  Most
> of the mistakes with non-radioactive drugs are due to busy staff, many of
> whom are undertrained.  Given the shrinking dollars used for medical care,
> most institutions try to "get away" with the lowest quality (and therefore
> cheapest) workers they can.

That might be true for "therapy doses", but what about all the other
misadministrations?
In a one year period in Texas there were at least 31 reported
misadministrations listed in the TDH"s incident report listed below.

LOCATION	ISOTOPE	CHEMFORM	CORRECT	AMOUNT	DATE
MED CENTER HOSP CONROE TX	TC-99	COLLOID	PERTECHNICATE	5000	10/6/95
S TEXAS NUCLEAR ASSOCIATES MCALLEN	TC-99	CHOLETEC	?	6800	11/28/95
ADVANCED MEDICAL IMAGING SAN ANTONIO	TC-99	CHOLTEC	TC-99	4800	11/27/95
KELSEY-SEYBOLD/SYNCOR HOUSTON	TC-99	PERTECHNETATE	20 MCI SESTAMBIBI
30000	12/8/95
BAYLOR UNIV MED CEN DALLAS	TC-99		1 MCI TH-210	26100	12/12/95
RAD PHYSICS ASSOC/SYNCOR SAN ANTONIO	TC-99	PERTECHNICATE	MDP	25000
1/23/96
SIERRA MED CEN EL PASO	TC-99	MEDRONATE	MDP	23800	1/25/96
SOUTHWESERN MED CEN DALLAS	TC-99	PERTECHNICATE	NONE(WRONG PATIENT	32800
2/5/96
ST MICHAEL CEN TEXARKANA	TC-99	PULMOLITE	NONE(WRONG PATIENT)	5200
12/11/95
METHODIST HOSP HOUSTON	TC-99		.5 MCI SULFUR COLLOI	22300	2/9/96
MALLENCKRODT MED CEN MESQUITE	TC-99		5 MCI SULFUR COLLOID	5000	2/19/96
MED CITY DALLAS	TC-99	CHOTEC	NONE(MRA SCAN)	5100	4/1/96
SPECIALTY PHARMACY TEMPLE	TC-99	MEBROFININ	MEDRONATE	25000	4/15/96
SPECIALTY PHARM TEMPLE	TC-99	MEBROFENIN	MEDRONATE	10000	4/13/96
SYNCOR/O'NILL SAN ANTONIO	TC-99	MDP	5MCI SULFOR COLLOID	20000	5/20/96
FREDERICKSBURG IMAGING FREDERICKSBURG	TC-99	DTPA	30MCI MDP	19800	5/15/96
ST MICHAEL TEXARKANA	TC-99	PERTECHNICATE	MDP		9/9/96
WEST TEXAS NUCLEAR MIDLAND	TC-99	MDP	CARDIOLITE	10000	5/21/96
SYNCOR/COLUMBIA EL PASO	TC-99	MDP ruled a medical	DTPA dose, used	8000
9/17/96
ST MICHAEL TEXARKANA	TC-99		NONE(WRONG PATIENT)	25010	6/17/96
SYNCOR/SPOHN CORPUS CHRISTI	TC-99	MDP	CHOLTEC	8000	7/3/96
COLUMBIA MED CEN LANCASTER	TC-99	MDP(TAG BROKEN)	MDP	20000	7/24/96
COOK CHILDRENS HOSP FT WORTH	TC-99	DTPA	6MCI MDP	1300	8/7/96
MD ANDERSON HOUSTON	GA-67	CITRATE	NONE	280	8/14/96
SYNCOR/HERMANN HOSP HOUSTON	TC-99	PERTECHNICATE	NEUROLITE	90000	9/3/96
SYNCOR/ARLINGTON ARLIGTON	TC-99	UNKNOWN	SESTAMIBI	29200	9/14/96
MALLINCKRODT UTSW MED CEN DALLAS	TC-99	MDP	DPTA	100000	10/8/96
SYNCOR INTERNATIONAL EL PASO	TC-99	CHOLETEC	MAA	5000	10/22/96
UT SW MED CEN DALLAS	TC-99	PERTECHNICATE	DMSA	1400	10/17/96
SHOLARS DRU/BAPTIST HOSP ORANGE	TC-99	PERTECHNICATE	CARDIOLITE		10/22/96

Charles Gallagher
Gammat@swbell.net
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