Re: medical misadministration - deja vu all over again

[Jim Vandergrift <jfvande@yahoo.com>]

Bill, I am not excusing and certainly agree that everything humanly
possible should be placed in the way of any mis-administration. 
However, I submit that those HP's in industry or other non-medical
areas of the "nuclear industry" would find it hard to understand the
"mind-set" of people who administer hundreds or thousands of curies of
activity to patients every month, intentionally. The vast majority of
these events are due to "human error" and the very human response of
administering radioactivity or radiation for good. I can certainly see
where this can lower ones threshold of vigilance. The HP in industry on
the other hand works in an environment in which the radiation /
radioactivity is, at best, a necessary evil.  I have to believe this
inherently keeps the HP and the worker more alert to and diligent to
avoiding all unnecessary exposure / contamination.
Of course having said this, it only increases the need for tight,
consistent, and practiced safeguards against the lapses that are known
will occur.    

--- William V Lipton <liptonw@dteenergy.com> wrote:
> 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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