another medical misadministration

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

Here's another one for all of you who think it doesn't happen often
enough to worry about.

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

Bill Lipton
liptonw@dteenergy.com

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

|General Information or Other                     |Event Number:
36142       |
+------------------------------------------------------------------------------+

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

| REP ORG:  KANSAS DEPT OF HEALTH                |NOTIFICATION DATE:
09/09/1999|
|LICENSEE:  UNIVERSITY OF KANSAS MEDICAL CENTER  |NOTIFICATION TIME:
17:33[EDT]|
|    CITY:  KANSAS CITY              REGION:  4  |EVENT DATE:
09/08/1999|
|  COUNTY:                            STATE:  KS |EVENT TIME:
11:45[CDT]|
|LICENSE#:                        AGREEMENT:  Y  |LAST UPDATE DATE:
09/09/1999|
|  DOCKET:
|+----------------------------+
|                                                |PERSON
ORGANIZATION |
|                                                |GARY SANBORN
R4      |
|                                                |JOSIE PICCONE
NMSS    |
+------------------------------------------------+
|
| NRC NOTIFIED BY:  RONALD FRASS (FAX)
|                             |
|  HQ OPS OFFICER:  WILLIAM POERTNER
|                             |
+------------------------------------------------+
|
|EMERGENCY CLASS:          N/A
|                             |
|10 CFR SECTION:
|                             |
|NAGR                     AGREEMENT STATE
|                             |
|
|                             |
|
|                             |
|
|                             |
|
|                             |
+------------------------------------------------------------------------------+

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

| POTENTIAL MEDICAL
MISADMINISTRATION.                                         |
|
|
| A patient was administered 5.4 millicuries of Indium-111.  The patient
was   |
| supposed to receive a dose of Chromium-51 for a blood volume test.
The      |
| preliminary investigation indicates a dose of 14 rads (cGy)  to the
spleen   |
| and less than 5 rads whole body.  The University of Kansas Medical
Center    |
| (KUMC) RSO was not available when the potential misadministration
occurred,  |
| and informed the Kansas Department Of Health And Environment (KDHE)
upon her |
| return to the office.  The KDHE and KUMC investigations have
commenced.  At  |
| this time, KUMC has no further information regarding this
event.             |
+------------------------------------------------------------------------------+





************************************************************************
The RADSAFE Frequently Asked Questions list, archives and subscription
information can be accessed at http://www.ehs.uiuc.edu/~rad/radsafe.html