ENS 41515

v t e ENS Event
15:00 Mar 21, 2005
Title	Medical Event - Total Dosage Delivered Is Less than the Prescribed Dosage
Event Description	During a quarterly review of written directives by hospital personnel, it was noted that a patient was administered a dosage of 12.51 millicuries of the isotope NaI-131 for hyperthyroidism instead of the prescribed dosage of 21 millicuries. Radiopharmaceutical unit dose dispensing records as well as internal scheduling paperwork confirm that the 12 millicuries dosage was in fact ordered and subsequently administered to the correct patient. The root cause of this event has been determined by the licensee to be lack of strict attention to detail and they have evaluated their policy and procedures to prevent reoccurrence. The attending physician has reviewed the patient's records and felt that there would be no adverse affect due to this misadministration. He will notify the patient regarding this incident.

ENS 41515 +/-
Where
Harper University Hospital Detroit, Michigan (NRC Region 3)
License number:	21-04127-02
Organization:	Harper University Hospital
Reporting

10 CFR 35.3045(a)(1)
Time - Person (Reporting Time:+21.47 h0.895 days <br />0.128 weeks <br />0.0294 months <br />)
Opened:	Thomas M. Kumpuris 12:28 Mar 22, 2005
NRC Officer:	Arlon Costa
Last Updated:	Mar 22, 2005
41515 - NRC Website
v • d • e

v t e Emergency Notification System
Harper University Hospital with 10 CFR 35.3045(a)(1)
WEEKMONTHYEAR2005-03-21T15:00:00 [Table view]
[ENS list for Harper University Hospital]

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