Home > NRC Library > ADAMS Public Documents

Final response to FOIA request for all diagnostic misadministration repts filed by Cleveland Clinic Foundation in Cleveland,OH.App A documents being made available in PDR.

Accession Number: ML20105B262

Date Released: Sunday, October 27, 2024

Package Contents

The following links on this page are to Adobe Portable Document Format (PDF) files. To obtain a free viewer for displaying this format, see our Plugins, Viewers, and Other Tools.

• ML20113H133 - Final response to FOIA request for all diagnostic misadministration repts filed by Cleveland Clinic Foundation in Cleveland,OH.App A documents being made available in PDR. (2 page(s), 11/4/1991)
• ML20113H180 - Informs of misadministration of radiopharms.Patient injected w/Tc-99m sodium pertechnetate rather than Tc-99m DTPA.Caused by technologist error.On 861118,dose infiltrated through closed peripheral line.Lines rechecked. (3 page(s), 1/8/1987)
• ML20113H194 - Informs of 901109 misadministration of radiopharm.Patient injected w/10.3 mCi Tc-99m DTPA.Caused by personnel error. (2 page(s), 11/19/1990)
• ML20113H196 - Informs of 910211 misadministration of radiopharm.Patient given .015 mCi INaI-131 instead of .10 mCi INaI-131.Imaging Technologist misunderstood physicians request.Signed worksheet will be attached to pick isotope request. (2 page(s), 2/18/1991)
• ML20113H203 - Informs of 910727 misadministration of radiopharm.Patient given 30 mCi Tc-99m PYP for lung vent study instead of 30 mCi DTPA.Reconstituted wrong reagent kit.Implemented new procedures for labeling & handling. (1 page(s), 7/29/1991)
• ML20113H182 - Informs of 970828 misadministration.of radiopharm.Patient received 0.56 mCi Tc-99m instrument calibr source labeled "Not for Human Use." Caused by personnel error.Technologist cautioned to recheck labels before injecting. (3 page(s), 9/3/1987)
• ML20113H187 - Informs of 880524 misadministration of radiopharm.Patient injected w/.611 mCi Tc-04-99 instead of 12 mCi Tc-99m DTPA for renal scan.Caused by personnel selecting wrong syringe from dosage cart.Personnel reinstructed. (2 page(s), 6/13/1988)
• ML20113H197 - Informs of 910412 misadministration of radiopharm.Employee received extremity exposure during 1st quarter of 1991. Caused by use of position emitting radioisotopes for care of nuclear medicine patients. (2 page(s), 4/15/1991)
• ML20113H168 - Informs of 801216 misadministration of radiopharm.Patient inadvertantly injected w/portion of bone scan dose,namely 7 mCi of T-99m metidronate,instead of liver scan.No ill effects noted.Adequate study obtained. (1 page(s), 1/5/1981)
• ML20113H208 - Informs of 910629 misadministration of radiopharm.Wrong patient given 21.2 mCi Tc-99m MDP instead of 10.0 mCi Tc-99m Mag-3.Caused by Technologist error.Procedures implemented for verification of patient identification. (2 page(s), 7/2/1991)
• ML20113H178 - Informs of misadministration of radiopharms.Patient incorrectly administered 250 uCi Tc-99m for renal scan instead of 12 mCi Tc-99m DTPA.Caused by failure to make positive identification of radiopharm. (1 page(s), 10/7/1986)
• ML20113H201 - Forwards two repts of misadministration of radiopharms on 910727 & 28. (1 page(s), 7/31/1991)
• ML20105B261 - Informs of 820317 misadministration of radiopharm.Patient injected w/50 uCi Yb-169 DTPA instead of 500 uCi.Dose inadequate for cisternography exam & will have to be repeated. (1 page(s), 3/24/1982)
• ML20113H199 - Informs of 910414 misadministration of radiopharm.Dose miscalulation for endobronchial application discovered. Incorrect calculation form put in practice in 1988.Physicist responsible never revised forms & left dept. (5 page(s), 4/26/1991)
• ML20113H192 - Informs of 900821 misadministration of radiopharm.Patient given 1 mCi Tc-99m sulfor colloid instead of 5 mCi Tc-99m disofenin.Caused by personnel misunderstanding physicians request.Personnel reprimanded. (2 page(s), 8/23/1990)
• ML20113H185 - Informs of 880517 misadministration of radiopharm.Patient injected w/11.5 mCi Tc-99m DTPA for renal scan.Caused by misunderstanding of referring physician request & not checking requisition.Personnel reprimanded. (2 page(s), 5/20/1988)
• ML20113H171 - Informs of 810522 misadministration of radiopharm.Patient inadvertently injected Tc-99m sulfur colloid.Bone scan done following day & revealed source of pain.Technologist involved admonished to check patient name w/isotope. (1 page(s), 5/27/1981)
• ML20113H189 - Informs of 880721 misadministration of radiopharm.Patient injected w/20 mCi Tc-0 instead of Tc-99m MDP.Caused by failure to read label & selection of wrong syringe.Personnel reinstructed. (2 page(s), 7/28/1988)
• ML20113H206 - Informs of 910728 misadministration of radiopharm.Patient given 30 mCi Tc-99m PYP for lung vent study instead of 30 mCi DTPA.Reconstitued wrong reagent kit.Implemented new procedures for labeling & handling. (1 page(s), 7/29/1991)