more on PA medical misadministration

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

Here's a more complete report on a medical misadminstration I posted
earlier.  This raises as many questions as it answers.  Two that come to
mind are:

Are there procedures for assuring that the right patient gets the right
radiopharmaceutical?

Has the hospital hp been involved in reviewing these procedures (No
procedure is, in fact, a  procedure that says, "Do anything you want.")
and assuring that they're followed?

Oh well, I've heard that the thyroid is highly overrated!

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

Bill Lipton
liptonw@dteenergy.com

September 17, 1999

PRELIMINARY NOTIFICATION OF EVENT OR UNUSUAL OCCURRENCE PNO-I-99-044

This preliminary notification constitutes EARLY notice of events of
POSSIBLE
safety or public interest significance. The information is as initially
received without verification or evaluation, and is basically all that
is
known by Region I staff in King of Prussia, Pennsylvania on this date.

Facility                                    Licensee Emergency
Classification
Holy Redeemer Hospital                        Notification of Unusual
Event
Holy Redeemer Hospital                        Alert
1648 Huntingdon Pike                          Site Area Emergency
Meadowbrook,Pennsylvania  19046               General Emergency
Dockets: 03003044 License No: 37-05089-01   X Not Applicable


Subject:  MEDICAL MISADMINISTRATION

The Licensee contacted the NRC Operations Center on September 16, 1999
at
2:15 p.m. to report that a patient who was to receive 300 uCi of
Iodine-123 for an uptake and scan procedure was inadvertently given 5
millicuries of NaI I-131.

On September 14, 1999, the patient arrived at the Nuclear Medicine
Department to have the study performed, without a referring physician
request.  The Nuclear Medicine Technologist returned the patient to the
referring physician to obtain a study request. The referring physician's

secretary provided a note to the patient that indicated "see this
patient
to evaluate for Iodine-131 treatment." The technologist administered 5
mCi of I-131 without an Authorized User-Physician Written Directive.

When the patient returned for the uptake study on the afternoon of
September 15, 1999, the patient brought a "referral" which stated,
"evaluate the patient for I-131 treatment for hyperthyroidism".  This
indicated that on the previous day the patient should have had an I-123
thyroid uptake and scan procedure.  The problem was identified at
approximately 3:00 p.m. on September 15, 1999.  The licensee stated that

the paperwork was very ambiguous, the procedure was ordered incorrectly,

no Written Directive was prepared by an Authorized User, and the
technologist failed to fill out a Quality Management Form.

Region I dispatched inspectors to the facility on September 17, 1999 to
examine the circumstances surround this event, root cause, and the
licensee's actions to prevent recurrence.

This information is current as of 10:30 a.m. on September 17, 1999.

The Region I Public Affairs Office is available to respond to public
inquiries.

The Commonwealth of Pennsylvania was informed.


Contact:  M. Beardsley          M. Shanbaky
          (610)337-6942         (610)337-5209




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