Misadministration means giving the radiopharmaceutical to the wrong patient, giving the wrong radiopharmaceutical or wrong activity to the patient, or unjustified examination of pregnant or lactating female patients. Another type of misadministration is to use the wrong route of administration, which includes complete extravascular injections that can result in very high absorbed exposure at the injection site especially if the volume is small, the activity is high, and the radiopharmaceutical has a long retention time.
The definition of wrong activity should be made locally. In general, a variation of ±25% from the prescribed activity is regarded as acceptable in diagnostic applications.
In order to avoid future accidents it is important to learn from previous ones. The initiating event and the contributing factors can always be identified. This information provides material that should be used to prevent future accidents. This is achieved by having an efficient reporting system and a programme for continuous education and training.
Yes. In order to avoid future accidents, it is important to learn from previous ones. The initiating event and the contributing factors can always be identified. It is necessary to have an efficient reporting system and a programme for continuous education and training. Furthermore, according to the BSS (II.29), registrants and licensees shall promptly investigate an incident. The investigation should be done as soon as possible and a written description of the incident should be prepared including:
A 43-year-old female patient was scheduled for a thyroid scan. She called the department in the morning and told the technologist that she was trying to get pregnant but there was no evidence at the moment that she was. She also wanted to discuss radiation risks and the justification of the examination. The technologist misunderstood the patient and thought she did not want to have the examination due to radiation risks in general. The technologist read the request and persuaded the patient to have the examination. Later, it appeared that the patient was in a very early stage of pregnancy.
According to the local rules of the department, this patient should be regarded as pregnant until otherwise proven. The technologist was not aware of this rule. It is beyond the responsibility of the technologist to discuss justification of an examination. That should be done by the nuclear medicine specialist.