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medical misadmin to hermaphrodite?
I've received a few comments saying I have an obsession with this.
Please note that I generally understand situations where the dose is off
by a little bit - try to avoid this, next time, but this happens. It's
the total screwups - wrong patient, wrong organ, wrong radionuclide that
are inexcusable.
BTW - Who wrote this alleged report? It's Tc99m, I hope, not Tc-99. If
the individual involved received dose to all of the organs stated he
(she? it?) has more problems than a few rems. (I hope I'm not trying to
practice medicine without a license.) If you screw up, at least write
a good report about it.
The opinions expressed are strictly mine.
It's not about dose, it's about trust.
Bill Lipton
liptonw@dteenergy.com
|General Information or Other |Event Number:
36333 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: KS DEPT of HEALTH & ENVIRONMENT |NOTIFICATION DATE:
10/22/1999|
|LICENSEE: CUSHING MEMORIAL HOSPITAL |NOTIFICATION TIME:
16:13[EDT]|
| CITY: LEAVENWORTH REGION: 4 |EVENT DATE:
09/20/1999|
| COUNTY: STATE: KS |EVENT TIME:
12:30[CDT]|
|LICENSE#: AGREEMENT: Y |LAST UPDATE DATE:
10/22/1999|
| DOCKET:
|+----------------------------+
| |PERSON
ORGANIZATION |
| |LINDA SMITH
R4 |
| |CHARLEY HAUGHNEY
NMSS |
+------------------------------------------------+
|
| NRC NOTIFIED BY: JUSTIN SPENCE
| |
| HQ OPS OFFICER: DICK JOLLIFFE
| |
+------------------------------------------------+
|
|EMERGENCY CLASS:
| |
|10 CFR SECTION:
| |
|NAGR AGREEMENT STATE
| |
|
| |
|
| |
|
| |
|
| |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| - AGREEMENT STATE REPORT - POTENTIAL MEDICAL MISADMINISTRATION
- |
|
|
| A POTENTIAL MEDICAL MISADMINISTRATION INVOLVING AN INCORRECT CHEMICAL
FORM |
| OF TECHNETIUM-99 OCCURRED ON 09/22/99. AT 1230 CDT, THE PATIENT
WAS |
| ADMINISTERED 25.8 MILLICURIES OF WHAT MAY HAVE BEEN TECHNETIUM-99
DTPA. THE |
| PATIENT WAS SCHEDULED TO RECEIVE A DOSE OF TECHNETIUM-99 MYOVIEW FOR A
HEART |
| SCAN. AN IMAGE OF THE KIDNEYS
AND |
| BLADDER WERE PRESENTED, BUT NO HEART IMAGE. THE RADIOLOGIST/RSO
WAS |
| IMMEDIATELY INFORMED. THE RADIOLOGIST CONFIRMED THE FINDINGS OF
THE |
| TECHNICIAN. THE LABEL FOR THE DOSE STATES THE RADIOPHARMACEUTICAL WAS
A |
| MYOVIEW DOSE. THE RADIOPHARMACY FROM WHICH THE DOSE WAS RECEIVED
BELIEVES |
| THAT THE CORRECT SUBSTANCE WAS ADMINISTERED. THE PATIENT AND
PHYSICIAN WERE |
| INFORMED THAT THE INCORRECT RADIOPHARMACEUTICAL HAD BEEN ADMINISTERED,
AND |
| THE CORRECT PROCEDURE WAS PERFORMED ON 09/23/99. DURING THE WEEK
OF |
| 10/04/99, THE CONSULTING PHYSICIST TO THE HOSPITAL WAS INFORMED.
ON |
| 10/17/99, THE PHYSICIST SENT A REPORT TO THE LICENSEE. IT WAS
DETERMINED |
| THAT THE CHEMICAL FORM OF THE RADIOPHARMACEUTICAL WAS PROBABLY DTPA.
THE |
| DOSE OF 25 MILLICURIES RESULTED IN A DOSE OF: TOTAL BODY 0.75 RAD,
BLADDER |
| 7.00 RAD, KIDNEYS 0.53 RAD, OVARIES 0.50 RAD, UTERUS 0.93 RAD, AND
TESTES |
| 0.35 RAD. THE CONSULTANT INSTRUCTED THE LICENSEE TO NOTIFY THE STATE
OF |
| KANSAS AND FILE A WRITTEN REPORT TO THE STATE OF KANSAS WITHIN 15
DAYS. |
|
|
| AT 0930 CDT ON 10/22/99, CUSHING MEMORIAL HOSPITAL TELEPHONED THE
KANSAS |
| RADIATION CONTROL PROGRAM IN ORDER TO INFORM THE AGENCY OF THE
EVENT |
| DESCRIBED ABOVE. THE KANSAS RADIATION CONTROL PROGRAM INITIATED
AN |
|
INVESTIGATION.
|
+------------------------------------------------------------------------------+
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