RE: medical misadmin

["Miron, Dan" <Dan.Miron@med.va.gov>]

>-----Original Message-----
>From: Glen.Vickers@ucm.com [mailto:Glen.Vickers@ucm.com]
>
>...Many of the problems are not technical at all, which means it probably
>wouldn't have taken that much effor to prevent the error...

Unfortunately it looks like the medical licensee would not have been able to
prevent this error since the radiopharmacy that supplied the dose appears to
have make the mistake according to the hospital.  25 mCi of Tc-99m in a dose
calibrator will read 25 mCi regardless of how it is tagged.

>-----Original Message-----
>From:	William V Lipton [SMTP:liptonw@dteenergy.com]
>
>...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.

It looks like the state of Kansas wrote this one (with information supplied
by the medical licensee) since it is an agreement state notification.  I am
glad am not in Kansas, Toto.

Unless the regs in Kansas are different than the NRC, this will not be a
misadministration.  A misadministration for the NRC is defined, in part, to
be the wrong radiopharmaceutical AND greater then 5 rem EDE or 50 rem dose
equivalent to any individual organ.  From the numbers given this event would
not be a misadministration according to the NRC.  But, definitely something
that needs to be investigated.

Dan
__________________________
Daniel J. Miron, Radiation Safety Officer (00S)
Zablocki VA Medical Center
5000 W. National Avenue
Milwaukee, Wisconsin 53295
(414) 384-2000 extension 2631
dan.miron@med.va.gov

"It is a strange person that would burn the flag of a country that would
let him do such a thing" -Author Unknown

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