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RE: medical misadmin
I think you should continue posting these medical mis-administrations. None
of us is ever as good as we think we are. We should look at all failures to
see if there is something we can use to improve ourselves and our programs.
My shipping program only approaches perfection when my coworker and I use
rigorous independent verification. Just going through the motions isn't
sufficient, both the performer of the task and independent verifier must
actually care be diligent at all times. These postings only serve to
validate the need for error checking mechanisms and those who will do their
best to perform their small part.
Many of the problems are not technical at all, which means it probably
wouldn't have taken that much effor to prevent the error.
Sincerely,
Glen Vickers
glen.vickers@ucm.com
> -----Original Message-----
> From: William V Lipton [SMTP:liptonw@dteenergy.com]
> Sent: Monday, October 25, 1999 7:55 AM
> To: Multiple recipients of list
> Subject: 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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