Lugol’s iodine dosage errors: Often neglected, underreported and a potentially fatal issue, but can it be circumvented?

2638 Objectives Routine patient preparation before radioactive iodine labeled studies includes oral administration of 100mg iodine 1 hour prior to administration of the tracer to prevent uptake and radiation to the thyroid gland. A 5% Lugol’s iodine is commonly used blocking agent. Given the varying iodine concentrations, a true iodine dosage is often “lost in translation” between the ordering physician and the prescribing pharmacy. At our institution, this culminated in atleast 2 patients presenting with thyroiditis and severe vomiting after having consumed a fatal dose of 100mL of Lugol’s instead of the prescribed 100mg iodine ( Methods Because symptoms of iodine overdose are typically silent, the true incidence of these medication errors is unknown and potentially underreported. Also, inadequate dosage occurs when patients are either A) uncertain of the need for the Lugol’s intake B) unable to find a pharmacy where Lugol’s is available or C) forgetful to take the dose. Technologists consider these instances generally unimportant and do not regularly report to the attending radiologists, thereby leading to unnecessary degradation of image quality and undesirable radiation dosage to the thyroid. A retrospective review of old radiology reports at our institution found there were no instances of appropriate documentation od these misadministrations and only infrequent mention of the resulting inappropriate thyroid blockade. Results An easy and effective solution to prevent this problem is to administer Lugol’s in the nuclear medicine under the supervision of the physician/technologist, rather than have the referring physicians directly prescribe the medication to the patient. In several instances, the pharmacists themselves did not kow why this was used and in what exact dosage it should be used. Conclusions Lugol’s misadministration represents a frequently encountered but underreported medication error in nuclear medicine practice. This easily preventable problem not only affects the study quality but when overdosed could result in lethal side effects.