ENS 40825

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v t e ENS Event
04:00 Jun 7, 2004
Title	Medical Event
Event Description	A 19 year old female was diagnosed with Grave's Disease of the thyroid. Consultation with an authorized user (a physician) was requested for consideration of Iodine-131 ablation of her thyroid gland. After this consultation, the patient wished to undergo radioactive iodine ablation of her thyroid gland. The physician completed a prescription in which his written directive was an order for 12 microCuries of Iodine-131. The word "micro" was written using the Greek alphabet letter. The technologist ordered 12 milliCuries of Iodine-131. The technologist received 12.5 milliCuries and this amount was administered orally on 4/7/04. The licensee became aware of this misadministration on 6/7/04 during their quarterly quality maintenance review. The licensee's review of this case with the physician revealed that his intent was to have ordered a 12 milliCurie dose. The physician wrote microCurie by mistake, as a microCurie dose would have been inappropriate for the clinical indication. There were no untoward affects from this administration. At this time, it is not known if the patient has been notified. Licensee RSO will provide that information at a later time. The licensee has reviewed this case and the sequence of events. The following action has been taken. The preprinted prescription form was modified such that after the blank where the authorized user enters the name of the isotope and the dose, the words "microCurie" and "milliCurie" will be written next to each other. The authorized user will need to circle one of the choices.

ENS 40825 +/-
Where
Rutland Regional Medical Center Rutland, Vermont (NRC Region 1)
License number:	44-14121-01
Organization:	Rutland Regional Medical Center
Reporting

10 CFR 35.3045(a)(1)
Time - Person (Reporting Time:+249.78 h10.408 days <br />1.487 weeks <br />0.342 months <br />)
Opened:	Paul Waite 13:47 Jun 17, 2004
NRC Officer:	Jeff Hixon
Last Updated:	Jun 17, 2004
40825 - NRC Website
v • d • e

v t e Emergency Notification System
Rutland Regional Medical Center with 10 CFR 35.3045(a)(1)
WEEKMONTHYEAR2004-06-07T04:00:00 [Table view]
[ENS list for Rutland Regional Medical Center]

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