ENS 41872

v t e ENS Event
14:00 Jul 22, 2005
Title	Medical Event - Administration of Lower Dose than Prescribed
Event Description	On July 22, 2005 a patient was administered a dose of 2.64 rem from a 66 mCi (millicurie) source of Sm 153 versus the intended dose of 4.28 rem for bone pain therapy. This was discovered later when the medical technologist questioned the dose and raised a question with the supervisor. When the technologists checked the calibration setting of the instrument used to measure the source they discovered that the calibration setting was incorrect. With the incorrect calibration setting a source of 66 mCi of Sm 153 was used versus the intended 107 mCi source. The prescribing physician will notify the patient's doctor who will contact the patient. There was no known adverse affect on the patient. The hospital took a corrective action of retraining and adding a check on their administration sheet that requires the technologist to check the instrument calibration setting. * * UPDATE TO NRC (HUFFMAN) FROM LICENSEE (WILLIAMS) AT 15:11 EDT ON 7/27/05 * * * The following follow-up calculations related to the dose were provided by the licensee: Whole body dose (assuming a qualify factor of 10) - 0.108 millisieverts per megabecquerel Bony Surfaces dose (assuming a qualify factor of 10) - 67.56 millisieverts per megabecquerel Bone Marrow dose (assuming a qualify factor of 10) - 15.37 millisieverts per megabecquerel R1DO (Meyers) notified.

ENS 41872 +/-
Where
Valley Health System Winchester, Virginia (NRC Region 1)
License number:	450158901
Organization:	Winchester Medical Center
Reporting

10 CFR 35.3045(a)(1)
Time - Person (Reporting Time:+98.17 h4.09 days <br />0.584 weeks <br />0.134 months <br />)
Opened:	Keri Williams 16:10 Jul 26, 2005
NRC Officer:	Pete Snyder
Last Updated:	Jul 27, 2005
41872 - NRC Website
v • d • e

v t e Emergency Notification System
Valley Health System with 10 CFR 35.3045(a)(1)
WEEKMONTHYEAR2005-07-22T14:00:00 [Table view]
[ENS list for Valley Health System]

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