ENS 40313

v t e ENS Event
17:15 Nov 10, 2003
Title	Less than Prescribed Dose to Patient
Event Description	The licensee received from the pharmacy a dose of Samarium-153 isotope (93.5 millicuries) scheduled to be administered to a patient for bone pain treatment. The dose calibrator at the hospital indicated that the assayed activity of the Samarium-153 was 9.39 millicuries. The licensee called the pharmacy and questioned about the discrepancy that the assayed activity needed to be multiplied by a factor of 10 which made the calculated value equal to 93.9 millicuries. The dose was then administered to the patient. About one hour later the pharmacy called and stated that the dose the patient received was in fact 9.39 millicuries of Samarium-153, realizing that the mistake was made due to the assumption that Samarium-153 is not just a pure beta emitter but actually gives off gamma radiation. The dose calibrator was accurate and the procedure was improperly followed by multiplying the assayed dose by a factor of 10. The physician, the Radiation Safety Officer and the patient were notified of the mistake. The physician will administer the rest of the dose to the patient. The licensee will make policy and procedural changes to reflect the fact that Quadramet Samarium-153 emits gamma radiation and can be properly measured by the hospital's calibrator.

ENS 40313 +/-
Where
Lakeland Medical Center St. Joseph, Michigan (NRC Region 3)
License number:	21-04177-01
Organization:	Lakeland Medical Center
Reporting

10 CFR 35.3045(a)(1)
Time - Person (Reporting Time:+16.98 h0.708 days <br />0.101 weeks <br />0.0233 months <br />)
Opened:	Todd Tschetter 10:14 Nov 11, 2003
NRC Officer:	Arlon Costa
Last Updated:	Nov 11, 2003
40313 - NRC Website
v • d • e

v t e Emergency Notification System
Lakeland Medical Center with 10 CFR 35.3045(a)(1)
WEEKMONTHYEAR2003-11-10T17:15:00 [Table view]
[ENS list for Lakeland Medical Center]

Navigation menu