Cdph 8453 Form PDF Details

When medical professionals navigate the complexities of diagnostic procedures, accuracy and precision are paramount to ensuring patient safety and effective treatment outcomes. In the realm of radiology and nuclear medicine, the margin for error is notably slim, given the potential for adverse effects resulting from misadministrations of radiopharmaceuticals. The State of California, through its Health and Human Services Agency and the California Department of Public Health Radiologic Health Branch, offers a crucial tool in safeguarding against such errors: the CDPH 8453 form. This form serves as a diagnostic misadministration report, a critical resource for reporting deviations from prescribed diagnostic procedures that incorporate radioactive materials. The form requests detailed information about the licensee, including their name and number, alongside specific event particulars like the date of occurrence, the type of misadministration - encompassing errors from administering the wrong radiopharmaceutical to dosage discrepancies exceeding 50%, among others. The document also probes into the event's contributory factors, from human error such as misunderstanding instructions or selecting the wrong patient, to systemic issues like heavy workload or procedural novelties. Furthermore, it mandates reporting on actions taken to prevent recurrence, illustrating a commitment to not only addressing individual incidents but also enhancing overall safety protocols. Each section of the form — from patient impact assessment to corrective actions — underscores the interconnectedness of procedure, oversight, and continuous improvement in the radiologic health landscape.

QuestionAnswer
Form NameCdph 8453 Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namescalibrator, Reinstruct, Radiologic, rhb

Form Preview Example

State of California—Health and Human Services Agency

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

California Department of Public Health

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Radiologic Health Branch

 

 

 

 

DIAGNOSTIC MISADMINISTRATION REPORT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Licensee name

 

 

 

 

 

 

 

 

 

 

 

 

 

Licensee number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address (number, street)

 

 

 

 

 

 

 

 

 

 

 

 

 

Event date

 

 

 

 

 

 

 

 

 

Report date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Month

Day

 

 

 

Year

 

Month

 

Day

Year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

ZIP code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Type of Misadministration

 

 

 

 

 

 

 

Did the misadministration involve an

Number of patients who received a

 

Wrong radiopharmaceutical

 

Dosage differing from prescribed by 50%

isotope of iodine?

 

 

 

 

 

 

 

misadministration under this report:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Wrong patient

 

Wrong route

 

 

 

 

 

Yes

 

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Intended

 

 

 

 

 

 

 

 

 

 

Intended

 

 

 

 

 

 

 

 

 

 

 

 

 

Given

 

 

 

No clinical procedure

 

 

Ultrasound

 

 

 

 

 

 

 

 

Chemical

 

 

 

 

 

 

 

 

 

 

 

 

 

Chemical

 

 

 

 

Nuclear medicine study (complete “Intended”

CT study

 

 

 

Millicuries

 

Isotope

 

Form

 

 

Study

 

Millicuries

 

Isotope

 

 

Form

 

Study

 

and “Given” sections)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NMR study

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

X-ray study

 

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Precipitator

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Referring physician

 

 

 

 

 

 

 

Authorized user

 

 

 

 

 

 

 

 

 

Hot lab technologist

 

 

 

Ward nurse

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Imaging technologist

 

 

 

Ward clerk

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Clinical receptionist

 

 

 

Nuclear pharmacy

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Scheduling technologist

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Patient

 

 

 

 

 

 

 

 

 

 

 

Name of nuclear pharmacy

 

 

 

 

 

 

 

City

 

 

 

 

 

 

State

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other:____________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Error

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hot Lab

 

 

 

 

Referral

 

 

 

Administration

 

 

 

 

 

 

 

 

 

 

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mislabeled a syringe

 

Selected wrong vial when

 

Misunderstood referring

 

Selected wrong patient

 

 

 

 

 

Specify

 

 

 

 

 

 

 

Mislabeled a vial or vial

 

drawing dosage

 

 

physician’s request

 

Answered waiting room

 

 

 

________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

shield

 

Set dose calibrator

 

 

Requested wrong study

 

page intended for other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Reconstituted wrong

 

improperly

 

 

Requested study for wrong

 

patient

 

 

 

 

 

 

 

 

________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

reagent kit

 

Misread dose calibrator

 

patient

 

 

 

 

 

Brought wrong patient to

 

 

________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

clinic

 

 

 

 

 

 

 

 

 

Placed reconstituted vial in

 

Misunderstood

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

________________________

 

wrong shield

 

radiopharmaceutical or

 

 

 

 

 

 

 

Selected wrong syringe

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

dosage order

 

 

 

 

 

 

 

 

from dosage cart

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Contributing Factors

 

 

 

 

 

 

 

 

Action Taken to Prevent Recurrence

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Student technologist

 

Requisition not checked

 

 

Implement new procedures for:

 

 

Improve supervision of personnel

 

New employee

 

Patient chart not checked

 

 

Verification of request

 

 

 

 

 

 

No action

 

 

 

 

 

 

 

Foreign language

 

New procedure

 

 

 

Radiopharmaceutical labeling

 

 

Other: _____________________

 

Patient incoherent or unconscious

Heavy workload

 

 

 

and handling

 

 

 

 

 

 

 

 

 

__________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Verification of patient

 

 

 

 

 

 

 

 

ID bracelet not checked

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

__________________________

 

 

 

 

 

 

 

 

 

 

identification

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Reinstruct personnel

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Reprimand personnel

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Effect on Patients

 

None apparent

 

 

See abstract

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Attach abstract and mail completed form to:

Compliance Unit

California Department of Public Health

Radiologic Health Branch, MS 7610

P.O. Box 997414

Sacramento, CA 95899-7414

For more information, go to www.dhs.ca.gov/rhb or phone (916) 327-5106.

Radiation Officer (printed name)

Signature

Telephone number

Date

CDPH 8453 (7/07)

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