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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       |
+------------------------------------------------------------------------------+

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

| 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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