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medical misadmin. - once more with feeling
An all too familiar type of event.
The opinions expressed are strictly mine.
It's not about dose, it's about trust.
Bill Lipton
liptonw@dteenergy.com
Hospital |Event Number:
36175 |
+------------------------------------------------------------------------------+
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| REP ORG: HOLY REDEEMER HOSPITAL |NOTIFICATION DATE:
09/16/1999|
|LICENSEE: HOLY REDEEMER HOSPITAL |NOTIFICATION TIME:
14:15[EDT]|
| CITY: MEADOWBROOK REGION: 1 |EVENT DATE:
09/15/1999|
| COUNTY: MONTGOMERY STATE: PA |EVENT TIME:
15:00[EDT]|
|LICENSE#: 37-05089-01 AGREEMENT: N |LAST UPDATE DATE:
09/16/1999|
| DOCKET:
|+----------------------------+
| |PERSON
ORGANIZATION |
| |NIEL DELLA GRECA
R1 |
| |JOSIE PICCONE
NMSS |
+------------------------------------------------+
|
| NRC NOTIFIED BY: PAT MAYNES
| |
| HQ OPS OFFICER: LEIGH TROCINE
| |
+------------------------------------------------+
|
|EMERGENCY CLASS: N/A
| |
|10 CFR SECTION:
| |
|LADM 35.33(a) MED MISADMINISTRATION
| |
|
| |
|
| |
|
| |
|
| |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| MEDICAL MISADMINISTRATION INVOLVING THE WRONG PHARMACEUTICAL AND THE
WRONG |
| DOSE AT HOLY REDEEMER HOSPITAL IN MEADOWBROOK,
PENNSYLVANIA |
|
|
| The Scheduling Department works independent from the Nuclear
Medicine |
| Department, and the individual who took the appointment scheduled
the |
| patient to have a I-131 total neck and body scan. This procedure
involves |
| the standard use of 5 mCi of I-131. The patient came in the next day
and |
| had no note. The patient was sent over to the referring physician,
and the |
| note was written in a very ambiguous manner. All it said was, "see
patient |
| to evaluate for I-131 treatment." The technologist who performed
the |
| procedure thought that an ablation was going to be ordered because it
was a |
| total neck and body scan, and the technologist administered the
5-mCi |
| capsule on
09/14/99. |
|
|
| When the patient returned for a study on the afternoon of 09/15/99
(the |
| following day), the patient brought along a referral. The referral
said, |
| "evaluate the patient for I-131 treatment for hyperthyroidism"
which |
| indicated that the patient should have had an I-123 uptake and
scan |
| involving about 300 µCi of I-123. This problem was identified
at |
| approximately 1500 on 09/15/99. The licensee stated that the
paperwork was |
| very ambiguous, the procedure was ordered incorrectly, and the
technologist |
| failed to fill out a quality management
form. |
|
|
| The licensee has the ability to scan the patient and give the doctor
the |
| patient's uptake on the I-131. Even though the wrong pharmaceutical
and the |
| wrong dose were administered, it is currently believed that the
patient may |
| need to receive additional I-131 therapy to slow the
thyroid. |
|
|
| The licensee notified the NRC Region 1 office (Shanbaky). The
licensee also |
| plans to notify the referring physician and the
patient. |
|
|
| (Call the NRC operations officer for a licensee contact telephone
number.) |
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