ENS Event | |
|---|---|
20:00 Apr 20, 2007 | |
| Title | Agreement State Report - Medical Misadministration |
| Event Description | North Carolina Radioactive Materials Branch was notified by the radiation safety officer from UNC Hospitals of a possible misadministration involving the administration of MDS Nordion Yttrium 90 microspheres. The licensee initially contacted us immediately on the next business day following the patient administration, but was not certain at the time if the event was a misadministration because calculations and measurements had to be made to determine the percentage of the prescribed dose delivered. The licensee has determined that the patient only received approximately 72% of the prescribed dose (22.6 millicuries), which qualifies the event as a misadministration under current North Carolina Regulations.
The misadministration occurred because of a leak in the administration set during delivery of the dose. The licensee has been asked to determine if the leak was because of an apparent manufacturing defect with the administration set, or the result of an assembly error by the licensee. The licensee will report the cause of the event in the Misadministration Report that must be submitted within 15 days of the event. No harm is expected to the patient because of this event. The patient's physician and authorized user will determine if an additional administration is necessary to account for the dose not delivered initially. North Carolina Report Number: NC-07-02 A "Medical Event" may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient. |
| Where | |
|---|---|
| Nc Div Of Radiation Protection Chapel Hill, North Carolina (NRC Region 1) | |
| License number: | 068-0565-1 |
| Organization: | Nc Div Of Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+228.07 h9.503 days <br />1.358 weeks <br />0.312 months <br />) | |
| Opened: | Unc Hospitals 08:04 Apr 30, 2007 |
| NRC Officer: | Jason Kozal |
| Last Updated: | Apr 30, 2007 |
| 43325 - NRC Website | |
Nc Div Of Radiation Protection with Agreement State | |
WEEKMONTHYEARENS 433252007-04-20T20:00:00020 April 2007 20:00:00
[Table view]Agreement State Agreement State Report - Medical Misadministration ENS 426042006-05-24T04:00:00024 May 2006 04:00:00 Agreement State Agreement State Report - Source Found on Beach ENS 408392004-06-24T04:00:00024 June 2004 04:00:00 Agreement State Agreement State Report - Tractor Trailer Leaking Radioactive Material 2007-04-20T20:00:00 | |