Re: medical misadmin. - once more with feeling

[carol marcus <csmarcus@ucla.edu>]

At 06:44 AM 9/17/99 -0500, you wrote:
>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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>
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Dear Radsafers:

This sounds like another example of an Authorized User physician who is not
managing his/her Nuclear Medicine practice because he/she doesn't know how,
and is trying to get a tech to practice medicine for him/her.  Was the
physician perchance a diagnostic radiologist with minimal Nuclear Medicine
training?

Fortunately, the patient was not harmed; an appropriate dose for
hyperthyroidism is almost always more than 5 mCi NaI-131.  However, this
case shows beautifully the complete failure of the "Quality Management" Rule
to affect "quality" or "management".  The root cause of the problem is that
this physician was able to obtain an NRC license.  NRC's qualification level
is low enough to include many physicians who are not competent in Nuclear
Medicine.  The negligence in this case must be shared by the NRC, which does
not assure competence, and cares mainly about User Fees, upon which its
survival depends.

I have been using byproduct material for about 40 years.  It seems to me
that as the years go by, NRC is running less and less of a "safety program",
and more and more of a "protection racket".

Ciao, Carol

Carol S. Marcus, Ph.D., M.D.
<csmarcus@ucla.edu>
Ciao, Carol

Carol S. Marcus, Ph.D., M.D.
<csmarcus@ucla.edu>

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