Re: Medical "Misadministrations"

[alstonc@odrge.odr.georgetown.edu]

Yes, the video described below is quite useful. I made it the centerpiece
of an inservice for the nuc med techs, many years ago, at another
institution, as a part of our response to a "misadministration."

In re the quotation marks, please note that it is pretty difficult to
achieve a true misadministration, in the strict, regulatory, sense, with
diagnostic quantities of radiopharmaceuticals. Most TEDE's are <20 mSv
(2000 mrem), and max organ dose equivalents are, usually, <500 mSv (50
rem). E.g., the incident in Kansas (assuming that it was DTPA, injected @
25.8 mCi) resulted in a TEDE of 0.8 rem (not a "total body" dose of "0.75
rad"), and a max organ dose of 7.2 rad (urinary bladder wall). The gonadal
doses would have been: ovaries >/= 0.5 rad and/or testes >/= 0.35 rad. 

I don't know what the rules are in Kansas, but, under NRC rules (when last
I knew them), the hospital described in the original posting went above and
beyond the call of duty, in reporting the misdosage. They should be
complimented for doing so, but I'm afraid that having it singled out on the
Internet, like that, just makes them look much worse than they probably
are. This is especially so, if it was truly, and only, the vendor's error.
I.e., if the hospital requested a dose of tetrofosmin, and the pharmacy
sent a dose of DTPA, marked as tet.

Finally, those of you in Agreement States may be able to borrow the video
from your local regulatory folks. The Washington Dept of Health lent me
theirs, lo those many years ago.

chris a.
alstonc@odrge.odr.georgetown.edu

P.S. "Myoview" is the tradename for tetrofosmin, which many people now use
instead of MIBI, for cardiac nuclear imaging.



At 11:50 AM 10/25/99 -0500, you wrote:
>Glen Vickers post reminded me of something.
>
>The NRC Produced a fairly good Medical Video and distributed it free to
>their licensees in 199, "good Practices in Preparing and Administering
>Radiopharmaceuticals".  It was produced  by the Office for Analysis and
>Analysis of Operational Data [AEOD] and distributed by the Office of Nuclear
>Material Safety and Safeguards.
>
>I just reviewed my copy and although a little dated I am going to show it to
>the NM Techs.  The video is based on data from misadministrations and
>emphasizes just the kind of errors Glen mentioned, wrong pharmaceutical,
>wrong patient, etc.
>
>My copy is not in good shape.  The tracking is off and adjustment doesn't
>seem to help.  I am going to inquire about the availability and cost from
>the NRC via their web site and will post the info.
>
>Any opinions expressed are mine alone and do not necessarily represent those
>of the Denver VA Medical Center, The Department of Veterans Affairs, or the
>U.S. Government.
>
>Peter G. Vernig                
>Radiation Safety Officer, VA Medical Center, 1055 Clermont St. Denver, CO
>80220, ATTN; RSO MS 115
>303-399-8020 ext. 2447, peter.vernig@med.va.gov [alternate
>vernig.peter@forum.va.gov] Fax 303-393-5026 [8 - 4:30 MT service] Alternate
>Fax 303-377-5686
>
>"You win some, you lose some, and some get rained out." Y. Berra
>
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