Information Notice 1985-61, Misadministrations to Patients Undergoing Thyroid Scans

Misadministrations to Patients Undergoing Thyroid Scans

ML031180147
Person / Time
Issue date:	07/22/1985
From:	Partlow J NRC/OI
To:
References
IN-85-061, NUDOCS 8504180445
Download: ML031180147 (3)

SSINS No.:

6835 IN 85-61

UNITED STATES

NUCLEAR REGULATORY COMMISSION

OFFICE OF INSPECTION AND ENFORCEMENT

WASHINGTON, D.C.

20555

July 22, 1985

IE INFORMATION NOTICE NO. 85-61:

MISADMINISTRATIONS TO PATIENTS

UNDERGOING THYROID SCANS

Addressees

Licensees authorized to use byproduct material for human applications.

Purpose

This information notice is intended to alert recipients of potentially

significant problems pertaining to human applications of byproduct material.

In four recent cases, because of errors, patients received significant, unnecessary radiation exposures.

It is expected that licensees will review

the information in this notice for applicability to their facilities and

consider actions, if appropriate, to preclude similar problems occurring at- their facilities.

However, suggestions contained in this information notice do

not constitute NRC requirements; therefore, no specific action or written

response is required.

Description of Circumstances

In the first case, a referring physician telephoned the hospital to request a

"radioactive iodine scan" for his patient.

The written request was to be for- warded to the nuclear medicine department at a later date.

When the patient

arrived at the nuclear medicine department, the written request had not arrived.

The nuclear medicine physician did not review the patient's history to evaluate

the need for this scan or direct which isotope to use.

The nuclear medicine

technologist had interpreted the physician's telephone order as a total-body

iodine-131 scan and administered a 5 millicurie dosage of iodine-131 to the

patient.

When the written request arrived at the hospital the next day, the

request was for a "thyroid scan," which required a 5 millicurie dosage of

technetium-99m.

As a result of the misadministration, the patient received a

dose of from 6500 to 9000 rads to the thyroid instead of the 0.7 rads that

would have resulted from the use of technetium-99m.

In the second case, a 5 millicurie dosage of iodine-131 was administered to

the wrong patient.

The patient's identification was not verified and the

iodine-131 was administered to a patient that was supposed to receive a 5 milli- curie dosage of technetium-99m.

8504180445

IN 85-61 July 22, 1985 In the third case, because of incorrect patient scheduling, a 10 millicurie

dosage of iodine-131 was administered to a patient instead of the intended

400 microcurie dosage of iodine-123.

The nuclear medicine physician had not

reviewed the patient's previous history and had not approved the nuclear medicine

procedure and related dosage.

In the fourth case, a patient, who was scheduled for a thyroid uptake and scan, received a dose of 1000 microcuries of iodine-131 instead of the intended 100

microcuries of iodine-131.

The hospital staff reported that this'misadminis- tration occurred because the involved personnel were unfamiliar with this

clinical procedure, which was not frequently performed.

Discussion:

Checking the patient's identification and previous history before approving

nuclear medicine procedures is very important, especially where ahigh dose to

the patient will result from the procedure.

It also is important for licensees

to establish written procedures for dosage preparation and administration and

to check the referring physician's written request-before administering the

dosage.

No specific action or written response is required by this information notice.

If you have any questions regarding this matter, please contact the Regional

Administrator of the appropriate NRC regional office or this office.

Jamqs G. Partlow, Director

Division of Inspection Programs

Office of Inspection and'Enforcement

Contact:

Harriet Karagiannis, IE

(301) 492-9655 Attachment:

List of Recently Issued IE Information Notices

Attachment

IN 85-61

July 22, 1985

LIST OF RECENTLY ISSUED

IE INFORMATION NOTICES

Information

Date of

Notice No.

Subject

Issue

Issued to

85-60

85-59 Defective Negative Pressure

7/17/85 Air-Purifying, Fuel Facepiece

Respirators

Valve Stem Corrosion Failures 7/17/85 Failure Of A General Electric 7/17/85 Type AK-2-25 Reactor Trip

Breaker

85-58

85-57

85-56

85-55

85-54

85-53 Lost Iridium-192 Source

Resulting In The Death Of

Eight Persons In Morocco

Inadequate Environment

Control For Components And

Systems In Extended Storage

Or Layup

Revised Emergency Exercise

Frequency Rule

7/16/85

7/15/85

7/15/85

All power reactor

facilities holding

an OL or CP

All power reactor

facilities holding

an OL or CP

All power reactor

facilities designed

by B&W and CE holding

an OL or CP

All power reactor

facilities holding

an OL or CP; fuel

facilities; and

material licensees

All power reactor

facilities holding

an OL or CP

All power reactor

facilities holding

an OL or CP

All NRC licensees

authorized to use

teletheraphy units

All power reactor

facilities holding

an OL or CP

All power reactor

facilities holding

an OL or CP

Teletheraphy Unit Malfunction 7/15/85 Performance Of NRC-Licensed

Individuals While On Duty

Errors In Dose Assessment

Computer Codes And Reporting

Requirements Under 10 CFR

Part 21

7/12/85

7/10/85

85-52 OL = Operating License

CP = Construction Permit