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Root Cause Analysis of Na131I Contamination

Establishing a cause-and-effect relationship for an adverse event is one of the key steps in preventing them and involves multiple people, resources, and steps, thus requiring a root cause analysis. Here, we describe a root cause analysis performed in the nuclear medicine department for an event involving Na131I contamination. Oral administration of Na131I in a capsule minimizes the risk of contamination and spills. However, the patient must be able to swallow a capsule. Na131I in capsule form is currently in widespread use for treatment of hyperthyroidism and thyroid cancer. Na131I in liquid form is rarely available immediately on demand and must be ordered at least 24–48 h in advance of the planned administration. The events leading to the incident, immediate remedial steps taken, and subsequent root cause analysis are described. The corrective actions taken after the root cause analysis, as well as the subsequent effectiveness of these actions, are mentioned. There may be one or multiple causes for an adverse event. It is important to identify the root cause. Corrective actions derived from the root cause can help prevent similar adverse events in the future. Therapeutic procedures in nuclear medicine involve unsealed radioactive sources, further adding a separate layer of immediate steps and reporting to the root cause analysis itself.