RE: medical misadmin. - once more with feeling

[Glen.Vickers@ucm.com]

I think all of these events should be posted on this forum.  They don't
necessarily need to be discussed, but they do tend to heighten our level of
awareness.

Glen Vickers
glen.vickers@ucm.com

	-----Original Message-----
	From:	William V Lipton [SMTP:liptonw@dteenergy.com]
	Sent:	Friday, September 17, 1999 6:44 AM
	To:	Multiple recipients of list
	Subject:	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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+---------------------------------------------------------------------------
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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
	|                             |
	|
	|                             |
	|
	|                             |
	|
	|                             |
	|
	|                             |
	
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	                                   EVENT TEXT
	
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	| 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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