Information Notice No. 85-61: Misadministrations to Patients Undergoing Thyroid Scans

                                                            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. 



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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