ENS 43325

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v t e 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.

ENS 43325 +/-
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
v • d • e

v t e Emergency Notification System
Nc Div Of Radiation Protection with Agreement State
WEEKMONTHYEAR2007-04-20T20:00:00 [Table view]
[ENS list for Nc Div Of Radiation Protection]

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