ENS Event | |
|---|---|
05:00 Dec 13, 2007 | |
| Title | Patient Received Less That Prescribed Dose |
| Event Description | On 12/13/07, a patient was scheduled for a thyroid ablation with 100 mCi of NaI-131. The dose arrived with 3 capsules totaling 95.5 mCi. The nuc med tech was unaware that the package contained 3 capsules due to lack of visualization. The nuc med tech administered 1 capsule with the activity of 21.39 mCi of NaI-131. The package was sent back to the pharmacy with the remaining 2 capsules of approximately 70 mCi of NaI-131.
The mistake was recognized the next morning. The radiologist was made aware of the situation and the patient notified immediately. The patient returned the morning of 12/14/07 and was administered the remaining 2 capsules totaling 69.7 mCi of NaI-131. Overall, the patient received a total of 91.09 mCi of Nal-131 over the course of 17 hours1.967593e-4 days <br />0.00472 hours <br />2.810847e-5 weeks <br />6.4685e-6 months <br />. 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 | |
|---|---|
| Hackley Hospital Muskegon, Michigan (NRC Region 3) | |
| License number: | 21-04125-01 |
| Organization: | Hackley Hospital |
| Reporting | |
| 10 CFR 35.3045(a)(1) | |
| Time - Person (Reporting Time:+538.33 h22.43 days <br />3.204 weeks <br />0.737 months <br />) | |
| Opened: | Carlo Santa Anna 15:20 Jan 4, 2008 |
| NRC Officer: | Jeff Rotton |
| Last Updated: | Jan 4, 2008 |
| 43882 - NRC Website | |
Hackley Hospital with 10 CFR 35.3045(a)(1) | |
WEEKMONTHYEARENS 438822007-12-13T05:00:00013 December 2007 05:00:00
[Table view]10 CFR 35.3045(a)(1) Patient Received Less That Prescribed Dose ENS 430822007-01-08T15:30:0008 January 2007 15:30:00 10 CFR 35.3045(a)(1), 10 CFR 35.3045(a)(3) Medical Event Under Dose to Intended Organ Due to Improper Seed Implant 2007-12-13T05:00:00 | |