ENS 46895

v t e ENS Event
04:00 Jan 1, 2005
Title	Agreement State Report - Dose Administered >20% Different from Prescribed Dose
Event Description	The following information was provided by the State of New York via email: A patient was prescribed 11 mCi of Iodine-131 for hyperthyroidism but received 7 mCi. Discovered during routine NYS DOH [New York State Department of Health] inspection on 10/18/2007. DOH staff reviewed a memo from the physicist to the RSO discussing the event, but their concern was only that the expiration date on the capsule was 12/28/04 (consultation with the pharmacy after the fact indicated that it was still acceptable to us this dose). A 'left-over' capsule from the previous week (15 mCi on 12/27/2004) with activity of 7 mCi on 01/01/2005 was administered to a patient who was prescribed 11 mCi with the permission of the RSO. Additional dose was ordered and an additional 4 mCi was administered the following day so they RSO did not think it was a misadministration. Follow-up letter from RSO concluded that there was no adverse effect on the patient. Corrective actions included changing procedures and staff training on proper course of action to take in the future and incident reporting requirements. Incident is closed. New York Report Id No.: NY-11-09 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 46895 +/-
Where
Not Provided Not Provided, New York (NRC Region 1)
License number:	NOT PROVIDED
Organization:	New York State Dept. Of Health
Reporting

Agreement State
Time - Person (Reporting Time:+56075.48 h2,336.478 days <br />333.783 weeks <br />76.812 months <br />)
Opened:	Robert Snyder 14:29 May 26, 2011
NRC Officer:	Howie Crouch
Last Updated:	May 26, 2011
46895 - NRC Website
v • d • e

v t e Emergency Notification System
Not Provided with Agreement State
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