This is a notification, pursuant to
10 CFR 35.3045, of a medical event that occurred at the
VA San Diego Healthcare System in San Diego,
California.
A dosage of 194 millicuries of I-131 sodium iodide was administered to a patient through a feeding tube on September 21, 2009. The patient was kept in a shielded room at the facility. Daily measurements of the exposure rate at one meter from the patient showed only a small decrease, consistent with radioactive decay, but not the expected biological elimination. The feeding tube was replaced on September 25, 2009. The activity in the feeding tube after removal from the patient was estimated as over 80 millicuries. At this time, it is estimated that the patient received less than half of the administered dose.
The basis for the medical event is that the total dosage delivered differs from the prescribed dosage by more than 20 percent. The facility has notified the patient of the medical event and is in the process of notifying the referring physician. The facility is in the process of assessing any possible medical effects on the patient.
The NHPP will perform a reactive inspection regarding the medical event. A 15-day written report for the medical event will be submitted to NRC Region III. National Health Physics Program will notify the NRC Project Manager, Cassandra Frasier, NRC Region III, of the medical event.
Additional information
The Department of Veterans Affairs holds NRC License No. 03-23853-01VA, a master materials license. Permits are issued under the license to Veterans Health Administration facilities. The VHA permit number for the facility involved in this medical event is 04-15030-01. National Health Physics Program makes required notifications to NRC.
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.