ENS 46861
ENS Event | |
|---|---|
04:00 Oct 2, 2007 | |
| Title | Agreement State Report - Patient Received Twice the Prescribed Dose |
| Event Description | The following report was received via fax.
New York law prohibits the release of any identifiers in cases of medical events. Therefore, the facility name etc. is not contained in this report. The licensee reported on 10/3/2007 that on 10/2/2007, a patient received 4 mCi 131 Iodine for a whole body scan instead of the 2 mCi that was ordered. The error was discovered after the radiopharmacy tried to reconcile their orders and shipments and found that a vial with 4 mCi [milliCurie] of 131 Iodine was missing and called the hospital. The nuclear medicine department staff inspected the waste sent from the department to the environmental services section of the hospital and found that the box they had sent did trigger an alarm and had been isolated. On closer inspection, they found one vial containing 2 mCi Iodine 131. An extra vial of Iodine 131 of 4 mCi (meant for another order) had been placed by the nuclear pharmacy in the box and sent along with the 2 vials of 2 mCi each. The technologist retrieved this mCi vial and one 2 mCi vial and gave the 4 mCi iodine capsule to the patient. The NM [Nuclear Medicine] technologist had retrieved 2 vials from the box on 10/2/2007. The order was for 2 vials, one for the patient dose and the other the standard. Failures: 1. She failed to verify that the labels on the dose vials matched the labels on the shipping box. 2. She failed to read the label on the vial containing the capsule that she gave to the patient. 3. She failed to assay the patient dose using the dose calibrator. 4. She failed to survey the box before sending it to the environmental services for disposal. All 4 failures are in violation of the licensee's protocol for the use of radioactive materials. The authorized user physician believes that the dose of 4 mCi for a whole body scan is still within the range in use at the facility and does not expect any harm to the patient as result of this event. A health physicist was consulted and doses to various organs were estimated and documented. To prevent a recurrence, they have implemented a TlME OUT protocol for administration of RAM [radioactive material], which requires that 2 technologists must agree on the correctness of the activity, assay and document it on both a hard copy log and the computer in the hot lab. These steps are adequate. This event is closed. New York Event Number: NY-11-03 New York State DOH Internal Tracking Number 566 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 | |
|---|---|
| None Provided None Provided, New York (NRC Region 1) | |
| License number: | NONE PROVIDED |
| Organization: | New York State Dept. Of Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+31810.05 h1,325.419 days <br />189.346 weeks <br />43.573 months <br />) | |
| Opened: | None Provided 14:03 May 19, 2011 |
| NRC Officer: | Mark Abramovitz |
| Last Updated: | May 19, 2011 |
| 46861 - NRC Website | |
None Provided with Agreement State | |
WEEKMONTHYEARENS 468612007-10-02T04:00:0002 October 2007 04:00:00
[Table view]Agreement State Agreement State Report - Patient Received Twice the Prescribed Dose ENS 468592007-07-02T04:00:0002 July 2007 04:00:00 Agreement State Agreement State Report - Medical Misadministration Using Hdr Afterloader ENS 468602007-06-20T04:00:00020 June 2007 04:00:00 Agreement State Agreement State Report - Medical Misadministration Using Hdr Afterloader 2007-07-02T04:00:00 | |