Protecting People and the EnvironmentUNITED STATES NUCLEAR REGULATORY COMMISSION
SSINS No.: 6835
IN 85-61
UNITED STATES
NUCLEAR REGULATORY COMMISSION
OFFICE OF INSPECTION AND ENFORCEMENT
WASHINGTON, D.C. 20555
July 22, 1985
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
forwarded 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
millicurie dosage of technetium-99m.
8504180445
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IN 85-61
July 22, 1985
Page 2 of 2
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 up, take 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 misadministration 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 a high 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.
Edward L. Jordan Director
Division of Emergency Preparedness
and Engineering Response
Office of Inspection and Enforcement
Contact: Harriet Karagiannis, IE
(301) 492-9655
Attachment:
List of Recently Issued IE Information Notices
