The following information was provided by the State of
North Carolina via email:
Pitt County Memorial Hospital, Inc. dba Vidant Medical Center (License No. 074-1457-1) had a medical event occur yesterday afternoon [08/05/2015]. In brief, a patient with a low GFR [Glomerular Filtration Rate] was being treated for thyroid carcinoma. The original plan was to give the patient 50 mCi of I-131, which was received, assayed and ready for the Radiologist's approval.
The Radiologist on site was not the original Radiologist who planned the treatment for this patient. The physician onsite felt that with the low GFR (score to indicate kidney function) a lower dose, 35 mCi, would be prudent and a second order was placed with the radiopharmacy.
Around 1200 EDT, the dose was received, assayed and ready for administration. The Radiation Safety Representative identified the patient as required and discussed the home-going instructions with the patient prior to the administration. After the patient acknowledged the instructions, the Radiation Safety Representative went to the hot lab, confirmed the written directive, identified an assayed dose with the patient's name on it (of which there were two), failed to confirm the activity on the pig and slip, and administered the dose.
The error was not identified until the hot lab nuclear medicine technologist noted that the 35 mCi dose was still in the hot lab. The Radiologist and Radiation Safety Office was notified immediately. As of 1420 EDT, the referring physician was notified and patient was to be notified by the end of the day. At this time, it is not probable that there will be any health impact from the discrepancy.
A NC Health Physicist will be doing a reactive inspection before the end of this week. The radiation safety team is conducting an investigation and will be filing a formal report (15-day report) by August 20, 2015.
NC NMED Report Identification number: NC150023
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.