ENS 47841

v t e ENS Event
04:00 Apr 13, 2012
Title	Agreement State Report - Radiotherapy Underdose
Event Description	The following report was received via fax: On April 13, 2012, a patient was to receive a prescribed dose of 100 mCi of iodine-131 (I-131) for thyroid cancer. Two capsules of I-131 were received from the radiopharmacy in a single vial which was assayed to assure proper dose prior to administering to the patient. The patient was given the contents of the vial for treatment and the treatment was considered complete. The Nuclear Medicine staff prepared the remaining container for return to the radiopharmacy on Monday April 16, 2012. The radiopharmacy picked up the I-131 container and returned it to their facility. Upon inspection of the returned package, the radiopharmacy discovered that one of the two capsules intended for the treatment remained lodged in the vial. The radiopharmacy informed Tristan and the RSO at 12:30 EDT on Monday April 16, 2012. The patient received 50 mCi of the intended 100 mCi dose. Patient and referring physician are in the process of being notified. The [PA] Department [of Radiation Protection] plans to do a reactive inspection on April 17, 2012. PA Event ID: PA120013 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 47841 +/-
Where
Pinnacle Health Hospitals Camp Hill, Pennsylvania (NRC Region 1)
License number:	PA-0037
Organization:	Pa Bureau Of Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+102.88 h4.287 days <br />0.612 weeks <br />0.141 months <br />)
Opened:	David Allard 10:53 Apr 17, 2012
NRC Officer:	Mark Abramovitz
Last Updated:	Apr 17, 2012
47841 - NRC Website
v • d • e

v t e Emergency Notification System
Pinnacle Health Hospitals with Agreement State
WEEKMONTHYEAR2012-04-13T04:00:00 [Table view]
[ENS list for Pinnacle Health Hospitals]

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