An analysis of reported incidents involving radiopharmaceuticals for the development of intervention strategies

Misadministrations and dose irregularities of radiopharmaceuticals are amon g the most common incidents reported to the Texas Department of Health Bure au of Radiation Control. In an effort to minimize future incidents, utility and process variable trends were evaluated using historical Texas Departme nt of Health Bureau of Radiation Control incident data. An analysis of misa pplication events (e.g., misadministration or dose irregularity) was perfor med by obtaining the quarterly incident summaries from the Texas Department of Health Bureau of Radiation Control for the study period 1988 to 1997. T he misapplication data accounted for 355 out of 2,126 (16.7%) incidents dur ing this period. The results indicate 94% of radiation source misapplicatio ns involved unsealed sources of radiation (e.g., radiopharmaceuticals). Add itionally, 73% of all self-reported events involved Tc-99m radiopharmaceuti cals. The most frequent radiation source process variable involved in the m isapplication was injecting an incorrect compound. The most widely utilized intervention to resolve the incident was training for the individuals resp onsible for drawing or administering the radiopharmaceutical. Universal app lication of these results are cautioned due to the bias associated with a s ingle-state study, changes in radiopharmaceutical use during the study peri od, and state-specific regulations which may vary in other study population s.