ENS 45005

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v t e ENS Event
04:00 Dec 22, 2008
Title	Mis-Administration of I-125 Subcutaneously Vice Intravenously
Event Description	The following abnormal occurrence information was received via e-mail: PA NMED PA090013. Date and Place: 12-22-2008; Hahnemann University Hospital, Philadelphia, PA. Procedure/Dose (Actual vs. Intended), Nature, and Probable Consequences: Patient prescribed 50 mCi of Iodine-125 monoclonal antibody to be administered intravenously. On December 22, 2008 the injection was made subcutaneously when patient's port was not located properly during the injection. Estimated skin dose is 360-710 rads. Notification: Patient was notified at the time of the event that the injection was subcutaneous rather than intravenous. Health Effect: Doctor is confident that the therapeutic effects of this dosage have still been received by the patient. There have been no noted skin effects reported to date. Cause or Causes: The nurse did not have the port completely visualized and admitted to not palpating the site as well as possible Actions Taken to Prevent Recurrence: Staff was retrained in December 2008 that patients with ports are to disrobe completely and be palpated to ensure that the injection is occurring within the port. State Agency: Just received notification of medical event, follow-up inspection to be performed by the State. This event is closed for the purpose of this report. 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 45005 +/-
Where
Hahnemann University Hospital Philadelphia, Pennsylvania (NRC Region 1)
License number:	PA-0927
Organization:	Pa Bureau Of Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+2887.43 h120.31 days <br />17.187 weeks <br />3.955 months <br />)
Opened:	David Allard 10:26 Apr 21, 2009
NRC Officer:	Karl Diederich
Last Updated:	Apr 21, 2009
45005 - NRC Website
v • d • e

v t e Emergency Notification System
Hahnemann University Hospital with Agreement State
WEEKMONTHYEAR2008-12-22T04:00:00 [Table view]
[ENS list for Hahnemann University Hospital]

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ENS Notification