ENS Event | |
|---|---|
15:00 Jun 12, 2006 | |
| Title | Overdose to Patients Thyroid |
| Event Description | The patient reported to the hospital for treatment Monday, June 12 at 11 am and was given 2 millicuries of I-131 as a thyroid treatment dose. The patient then returned on June 14, 2006, for a survey. The prescribing physician reviewed and checked the orders as sufficient for a medistatic survey. The survey results revealed that there was a 96 percent uptake to the thyroid. Using the survey results, a discrepancy was discovered. During an initial interview of the patient it was not determined that the patient had no prior history of cancer or any prior history of operations on the thyroid. Since the patient had no prior history it was determined that a dose of 200 microcuries of I-131 should have been used.
The results of this overdose could include loss of thyroid function. The consequences and possible remedies have been discussed with the patient. The hospital plans on changing their interview sheet to a checklist type format to help avoid this problem in the future. The hospital also plans on performing a root cause analysis on this issue. |
| Where | |
|---|---|
| Battle Creek Health System Battle Creek, Michigan (NRC Region 3) | |
| License number: | 21-01354-04 |
| Organization: | Battle Creek Health System |
| Reporting | |
| 10 CFR 35.3045(a)(1) | |
| Time - Person (Reporting Time:+48.88 h2.037 days <br />0.291 weeks <br />0.067 months <br />) | |
| Opened: | Kelly Allen 15:53 Jun 14, 2006 |
| NRC Officer: | Pete Snyder |
| Last Updated: | Jun 14, 2006 |
| 42639 - NRC Website | |
Battle Creek Health System with 10 CFR 35.3045(a)(1) | |
WEEKMONTHYEARENS 426392006-06-12T15:00:00012 June 2006 15:00:00
[Table view]10 CFR 35.3045(a)(1) Overdose to Patients Thyroid 2006-06-12T15:00:00 | |