ENS 49269
ENS Event | |
|---|---|
04:00 Aug 7, 2013 | |
| Title | Agreement State - Patient Received 20% Lower than I-131 Prescribed Dose |
| Event Description | The following Georgia Agreement State report was received via email.
Event Description: Patient was scheduled for an I-131 prescribed dose of 100-150mCi for the treatment of Thyroid Carcinoma. The patient instead was administered a dose that deviated 20% lower than the prescribed dose. This incident was reported to the [Georgia] State per Rule 391-3-17.05(115)(a)1.(i): 'A dose that differs from the prescribed dose by more than 0.05 Sv (5 rem) effective dose equivalent, 0.5 Sv (50 rem) to an organ or tissue, or 0.5 Sv (50 rem) shallow dose equivalent to the skin; and either (i) The total dose delivered differs from the prescribed dose by 20 percent or more.' The State will provide the corrective action information when provided by the licensee. GA State Report ID: CTS 71850 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.
A sodium iodine I-131 thyroid ablation treatment was ordered as a NaI I-131 whole body scan resulting in a patient receiving a diagnostic dose of 5 mCi of NaI (I-131) instead of the therapeutic dose of 50 mCi of NaI (I-131). Both the referring physician and the patient were also informed of the misadministration of the 5 mCi I-131 dose for the whole body scan on August 7, 2013 in light of the confirmed order for an I-131 thyroid ablation. The order verification process was reviewed with all involved staff members and an extensive review of the process was begun. Nuclear Medicine, like all diagnostic services, requires verification of the order for services. This verification must be in the form of a written order or an electronic authenticated order. On August 1, 2013 Piedmont Hospital Atlanta implemented EPIC, a new electronic medical record (EMR). The orders verification process changed a bit, because Piedmont Physician Groups could place an order within the EPIC environment (EPIC Physicians) and have them electronically authenticated, with e-signature and a time stamp. Physicians not in the EPIC environment (non-EPIC Physicians) could still schedule services through scheduling by providing a written order. Once scheduling had received a written order, the ancillary orders process would produce an order that looked just like the order produced by an EPIC physician, but the chart would have a paper clip to signify that it was a non-EPIC Physician order. During the first week of the EPIC implementation, many of the orders that were transcribed by the scheduling services department did not have the attachment of the original written order. This information came to light during the first few days of go-live but not all end users were informed on the issue. In this particular case, the patient's order was requested by a non-EPIC physician, as an I-131 whole body scan. The order was transcribed by scheduling , and as of August 7, 2013, the original order was not scanned into the chart. The order in the chart appeared to be an EPIC Physician order. Based on the information known at the time, the order for an I-131 whole body scan was verified and the patient was dosed and instructed to return on Friday August 9, 2013 for imaging. On August 8, 2013, a copy of the original order was scanned into the patient's record. The order contained more detailed information concerning the reason for the referral to nuclear medicine. This information would prove to be vital in determining the actual course of treatment requested by the referring physician. On Friday August 9, 2013, the patient returned for the whole body scan, but due to a downed system at the hospital the patient was referred to the Piedmont West Imaging Center to complete their test. While preparing the report template in PACs (Name removed), noticed that the patients chart had a paper clip icon but the documentation that she had received from the hospital Nuclear Medicine department only had an EPIC Physician order. (Name removed) opened the original scanned order for an I-131 whole body scan and discovered that within the comments section of the note that the Authorized User was referring the patient for an I-131 thyroid ablation. The office was contacted, and the order for an I-131 thyroid ablation was confirmed. (Name Removed), contacted the RSO to inform him of the events leading up to this misadministration. The actions taken to prevent a future reoccurrence of a similar event include: -Training on the orders verification process in EPIC for all Nuclear Medicine staff members -Defining the difference between an EPIC Physician order and a non-EPIC Physician order -All non-EPIC Physician orders must have an attached copy of the original order or a call must be placed to the provider's office requesting a copy of the order if the patient does not have an original copy. Notified R1DO (Schmidt) and FSME (via email). |
| Where | |
|---|---|
| Piedmont Hospital Atlanta, Georgia (NRC Region 1) | |
| License number: | GA 292-1 |
| Organization: | Georgia Radioactive Material Pgm |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+133.18 h5.549 days <br />0.793 weeks <br />0.182 months <br />) | |
| Opened: | Travis Cartoski 17:11 Aug 12, 2013 |
| NRC Officer: | John Shoemaker |
| Last Updated: | Aug 20, 2013 |
| 49269 - NRC Website
Loading map... | |
Piedmont Hospital with Agreement State | |
WEEKMONTHYEARENS 570112024-03-05T05:00:0005 March 2024 05:00:00
[Table view]Agreement State Misadministration ENS 492692013-08-07T04:00:0007 August 2013 04:00:00 Agreement State Agreement State - Patient Received 20% Lower than I-131 Prescribed Dose 2024-03-05T05:00:00 | |