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.
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. |
| 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 | |
Valley Health System with 10 CFR 35.3045(a)(1) | |
WEEKMONTHYEARENS 418722005-07-22T14:00:00022 July 2005 14:00:00
[Table view]10 CFR 35.3045(a)(1) Medical Event - Administration of Lower Dose than Prescribed 2005-07-22T14:00:00 | |