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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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