ENS 44045

v t e ENS Event
06:00 Mar 6, 2008
Title	Agreement State Report - Possible Patient Underdoses
Event Description	The Department of Health and Family Services (DHFS) was notified on March 6, 2008, of possible underdoses to up to eight patients treated with Samarium-153 since late 2006. When the licensee was preparing a recent dose of Samarium-153, the activity measured in the dose calibrator did not read as expected. After review, the licensee determined that the dose calibrator was calibrated to measure Samarium-153 in a vial, but the nuclear medicine technologist had measured the activity of Samarium-153 in a syringe instead. For this particular case, the dosage was remeasured properly prior to administration, but further review of cases identified up to eight additional instances when the nuclear medicine technologists may have measured the activity of Sarnarium-153 in a syringe instead of in a vial. Samarium-153 has a combined beta and gamma decay spectrum, and when the activity is measured in a syringe, the attenuation and volume geometry is estimated to lead to administered activities of approximately 30% less than prescribed in the written directives. DHPS will investigate this incident next week. 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 44045 +/-
Where
Appleton Medical Center Appleton, Wisconsin (NRC Region 3)
License number:	087-1014-01
Organization:	Wisconsin Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+34.53 h1.439 days <br />0.206 weeks <br />0.0473 months <br />)
Opened:	Megan Shober 16:32 Mar 7, 2008
NRC Officer:	Pete Snyder
Last Updated:	Mar 7, 2008
44045 - NRC Website
v • d • e

v t e Emergency Notification System
Appleton Medical Center with Agreement State
WEEKMONTHYEAR2008-03-06T06:00:00 [Table view]
[ENS list for Appleton Medical Center]

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