ENS 41860

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v t e ENS Event
15:00 Jul 20, 2005
Title	Medical Event - Delivered Dosage Exceeded Prescribed Dosage
Event Description	{{#Wiki_filter:On Wednesday July 20, 2005 it was discovered, during a routine audit of the Nuclear Medicine records, that two patients were administered I-131 in amounts exceeding 30 microcuries without a written directive. Furthermore, the doses fell more than 20% outside the prescribed dose range as set by the Authorized User (AU) physician. Below I will discuss the particulars of each administration. 1. Patient #1: 25 year old female was administered 31 �Ci of I-131 Sodium Iodide (Nal) on 18 July 2005 without a written directive prepared or signed by the AU previous to administration. The purpose of the study was to ascertain the thyroid uptake fraction and image the thyroid tissue. The prescribed does range, as set by the AU, was 8 to18 microcuries. This dose was 72% higher than the maximum dose allowed by the AU for this diagnostic procedure. (The patient's actual 24-hour thyroid uptake fraction was 27.5%). 2. Patient #2: 61 year old female was administered 42 �Ci of I-131 Nal on 14 July, 2005 without a written directive prepared or signed by the AU previous to administration. The purpose of the study was to ascertain the thyroid uptake fraction and image the thyroid tissue. This dose was 133% higher than the maximum dose allowed by the AU for this diagnostic procedure. (The patient's actual 24-hour uptake fraction was 14%). Dose Estimates From These Procedures 1. Patient #1: Using data found in NUREG CR-6435 "Radiation Dose Estimated from Radiopharmaceuticals" we estimate the following doses for the (a) Whole Body: 1.209 rem, and (b) Thyroid (target organ) 40.3 rad 2. Patient #2: Using data from NUREG CR-6345 and from other sources we estimate the following dose for the (a) Whole Body: 1.638 rem, and (b) Thyroid: 17.6 rad. }}

ENS 41860 +/-
Where
Montgomery Regional Hospital Blacksburg, Virginia (NRC Region 1)
License number:	45-19057-01
Organization:	Montgomery Regional Hospital
Reporting

10 CFR 35.3045(a)(1)
Time - Person (Reporting Time:+23.5 h0.979 days <br />0.14 weeks <br />0.0322 months <br />)
Opened:	James Nunn 14:30 Jul 21, 2005
NRC Officer:	John Knoke
Last Updated:	Jul 21, 2005
41860 - NRC Website
v • d • e

v t e Emergency Notification System
Montgomery Regional Hospital with 10 CFR 35.3045(a)(1)
WEEKMONTHYEAR2005-07-20T15:00:00 [Table view]
[ENS list for Montgomery Regional Hospital]

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