The following report was submitted via e-mail:
On January 16, 2008, Saint John Medical Center (SJMC) Lic. # OK-00376-02, of Tulsa, OK notified the Oklahoma Department of Environmental Quality (ODEQ) that on January 10, 2008 a patient had been administered a dose of I-131 that differed from the intended dose by greater than 20%. The intended dose was 100 mCi. The administered dose was 25 mCi. The misadministration occurred because the 100 mCi dose provided by Nuclear RX, PC (NRX) Lic. # OK-31035-01MD of Tulsa, OK was divided among three capsules. Two capsules contained 25 mCi, while the third contained 50 mCi I-131. The bottle received by SJMC was opaque and stated that it contained one capsule of 309 mCi because of a software error at NRX. When the dose was administered to the patient, one capsule was dispensed from the bottle, while the other two stuck in the bottom of the bottle. The presumed empty bottle was then repackaged and shipped back to NRX where it was discovered that two capsules remained in the bottle. It was determined that the capsules contained a total of 75 mCi I-131. The capsules were not discovered before shipping because the tech at SJMC errantly surveyed the package before placing the bottle inside. Corrective actions by SJMC involve surveying the bottle prior to returning it to the transport shielding, refresher training on transport requirements in 49 CFR, and determining the transport index (TI) by survey outside of the hot lab. Corrective actions by NRX included contacting the software developer for an update that would ensure that all shipments are accurately labeled. NRX also agreed to write the number of capsules contained in each bottle on the lid of the bottle.
Due to an oversight, this event was not reported at the time it was received by ODEQ.
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.