ENS 47227

v t e ENS Event
05:00 Aug 30, 2011
Title	Agreement State Report - Patient Received Wrong Isotope During a Diagnostic Procedure
Event Description	The following information was obtained from the State of Wisconsin via facsimile: The Wisconsin Department of Health Services (DHS) received a phone call from the Imaging Manager at Aurora Medical Center of Washington County on August 30, 2011, that a patient received a dose of 5 mCi of I-131 on February 2, 2011. The patient, according to the written directive, was to receive a dose of 5 mCi of I-123. This diagnostic procedure was ordered to evaluate whether any thyroid tissue remained following an iodine ablation dose one year earlier. DHS conducted an investigation on August 31, 2011 and the licensee will submit a 15-day written report concerning the medical event. At this time, the licensee is evaluating their process and is developing a new written directive form. The authorized user will discuss this with the referring physician to determine if the patient will be notified. Wisconsin Report ID: WI110013 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 47227 +/-
Where
Aurora Medical Ctr. Of Washington Co., Inc. Hartford, Wisconsin (NRC Region 3)
License number:	131-1024-01
Organization:	Wisconsin Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+35.25 h1.469 days <br />0.21 weeks <br />0.0483 months <br />)
Opened:	Krista Kuhlman 16:15 Aug 31, 2011
NRC Officer:	Howie Crouch
Last Updated:	Aug 31, 2011
47227 - NRC Website
v • d • e

v t e Emergency Notification System
Aurora Medical Ctr. Of Washington Co., Inc. with Agreement State
WEEKMONTHYEAR2011-08-30T05:00:00 [Table view]
[ENS list for Aurora Medical Ctr. Of Washington Co., Inc.]

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