Re: medical misadministration of I-131

[carol marcus <csmarcus@ucla.edu>]

At 08:06 AM 8/13/99 -0500, you wrote:
>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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Dear Radsafers:

Only 31 diagnostic misadministrations?  That's wonderful.  As they don't
cause harm, they're not important.  What is your x-ray retake rate?  10 or 15%?

Ciao, Carol


Carol S. Marcus, Ph.D., M.D.
<csmarcus@ucla.edu>

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