ENS 48444

v t e ENS Event
18:00 May 1, 2012
Title	Radiopharmaceutical Therapy Record Transposition Error
Event Description	A doctor prescribed a patient 0.4 mCi/Kg Zevalin (a prescription medication containing Yttrium-90). The calculated dose based on the patient's weight was 44 mCi; however, the package insert for the drug says the maximum dose to be used is 32 mCi. So 32 mCi of Y-90 was to be given to the patient. A radiopharmaceutical therapy record was prepared as required at the hospital but the dose on the radiopharmaceutical therapy record was improperly copied as 23 mCi. The dose prepared at the radiopharmacy and delivered to the patient was 31.8 mCi. The dose differed from that specified on the radiopharmaceutical therapy record by more than 20%. The prescribing physician is aware and there is no significant impact to the patient. 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 48444 +/-
Where
Missouri Babtist Medical Center St. Louis, Missouri (NRC Region 3)
License number:	24-1128-02
Organization:	Missouri Baptist Medical Center
Reporting

10 CFR 35.3045(a)(1)
Time - Person (Reporting Time:+4245.9 h176.913 days <br />25.273 weeks <br />5.816 months <br />)
Opened:	Thomas Moenster 15:54 Oct 25, 2012
NRC Officer:	Pete Snyder
Last Updated:	Oct 25, 2012
48444 - NRC Website
v • d • e

v t e Emergency Notification System
Missouri Babtist Medical Center with 10 CFR 35.3045(a)(1)
WEEKMONTHYEAR2012-05-01T18:00:00 [Table view]
[ENS list for Missouri Babtist Medical Center]

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