An analysis of reported incidents involving radiopharmaceuticals for the development of intervention strategies.
Misadministrations and dose irregularities of radiopharmaceuticals are among the most common incidents reported to the Texas Department of Health Bureau of Radiation Control. In an effort to minimize future incidents, utility and process variable trends were evaluated using historical Texas Department of Health Bureau of Radiation Control incident data. An analysis of misapplication events (e.g., misadministration or dose irregularity) was performed by obtaining the quarterly incident summaries from the Texas Department of Health Bureau of Radiation Control for the study period 1988 to 1997. The misapplication data accounted for 355 out of 2,126 (16.7%) incidents during this period. The results indicate 94% of radiation source misapplications involved unsealed sources of radiation (e.g., radiopharmaceuticals). Additionally, 73% of all self-reported events involved 99Tc radiopharmaceuticals. The most frequent radiation source process variable involved in the misapplication was injecting an incorrect compound. The most widely utilized intervention to resolve the incident was training for the individuals responsible for drawing or administering the radiopharmaceutical. Universal application of these results are cautioned due to the bias associated with a single-state study, changes in radiopharmaceutical use during the study period, and state-specific regulations which may vary in other study populations.
Charlton
M A
MA
Institutional Safety Office, University of Texas Health Science Center, San Antonio 78229-7928, USA. charlton@uthscsa.edu
Emery
R J
RJ
D006801:Humans; D008508:Medication Errors; D011829:Radiation Dosage; D011835:Radiation Protection; D019275:Radiopharmaceuticals / Q000009:adverse effects*
D019275:Radiopharmaceuticals