medical misadministration - deja vu all over again

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

Please see attached.  This time, they got an 18 month old.

I know there's a lot of WORK going on, but the health physics
"profession" should seriously consider intervening in some way.

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

Bill Lipton
liptonw@dteenergy.com

Hospital                                         |Event Number:
36076       |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+

| REP ORG:  REYNOLDS ARMY COMMUNITY HOSPITAL     |NOTIFICATION DATE:
08/26/1999|
|LICENSEE:  REYNOLDS ARMY COMMUNITY HOSPITAL     |NOTIFICATION TIME:
15:26[EDT]|
|    CITY:  FT. SILL                 REGION:  4  |EVENT DATE:
08/26/1999|
|  COUNTY:  COMANCHE                  STATE:  OK |EVENT TIME:
09:51[CDT]|
|LICENSE#:  35-10202-01           AGREEMENT:  N  |LAST UPDATE DATE:
08/26/1999|
|  DOCKET:
|+----------------------------+
|                                                |PERSON
ORGANIZATION |
|                                                |PHIL HARRELL
R4      |
|                                                |JOSEPHINE PICCONE
NMSS    |
+------------------------------------------------+
|
| NRC NOTIFIED BY:  ANDREA GRINDSTAFF
|                             |
|  HQ OPS OFFICER:  STEVE SANDIN
|                             |
+------------------------------------------------+
|
|EMERGENCY CLASS:          N/A
|                             |
|10 CFR SECTION:
|                             |
|LADM 35.33(a)            MED MISADMINISTRATION
|                             |
|
|                             |
|
|                             |
|
|                             |
|
|                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT
+------------------------------------------------------------------------------+

| MEDICAL MISADMINISTRATION INVOLVING DIAGNOSTIC DOSE GIVEN TO
INCORRECT       |
|
PATIENT
|
|
|
| AT APPROXIMATELY 0951CDT ON 8/26/99, AN 18-MONTH OLD INFANT RECEIVED
A       |
| SINGLE 1 cc DOSE CONTAINING 1.1 mCi OF TECHNETIUM-99m (MDP) INTENDED
FOR     |
| ANOTHER PATIENT.  THE PRESCRIBING PHYSICIAN AND THE INFANT'S PHYSICIAN
WERE  |
| BOTH INFORMED.  THE INFANT'S FAMILY WAS INFORMED BY THEIR PHYSICIAN.
THE    |
| HOSPITAL ATTRIBUTES THE MISADMINISTRATION TO AN ADMINISTRATIVE ERROR
AND     |
| DOES NOT EXPECT ANY ADVERSE HEALTH
CONSEQUENCES.                             |
|
|
| (CALL THE NRC OPERATIONS OFFICER FOR A LICENSEE CONTACT ADDRESS
AND          |
| TELEPHONE
NUMBER.)                                                           |
+------------------------------------------------------------------------------+




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