The following report was received from the State of
Mississippi via email:
On 9-10-2012, the licensee administered 163 mCi of I-131 from an admission order dated 9-6-2012, instead of the prescribed 100 mCi of I-131 from the written directive dated 9-5-2012. The licensee's investigation revealed a misinterpretation of an admission order as a written directive by the nuclear medicine technologist due to inclusion of the authorized user's name and 150 mCi of a radionuclide activity on the admission order. The written directive was never received by the Nuclear Medicine Department. The licensee determined the root cause of the error stemmed from a new communication process by which written directives are conveyed from the authorized user to Central Scheduling and then to the Nuclear Medicine Department.
The administered dose is described as not out of line with doses typically prescribed for patients with similar disease and the authorized user indicates an expectation of no adverse effect for the patient. The referring physician and patient were both notified on 9-10-2012 by the authorized user.
The licensee is correcting its procedure for written directives and how they are communicated to the Hospital's Nuclear Medicine Department and will submit them for review to DRH.
Mississippi Event Report No.: MS-267-01
A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.
- * * UPDATE FROM MOAK TO SNYDER ON 9/28/12 AT 1656 EDT * * *
[The] licensee's inspection revealed the medical event was an isolated incident. The new procedures for communicating written directives were only in place for two (2) months with one (1) I-131 administration during this time. The licensee has since changed back to their old procedures where written directives are communicated directly from the authorized user to the nuclear medicine department.
Notified R4DO (O'Keefe) and
FSME Event Resource (e-mail).