ENS 50692

v t e ENS Event
02:00 Dec 17, 2014
Title	Prescribed Dose Changed by Unauthorized User
Event Description	On 16 December 2014, at 1800 [PST], a patient was prescribed to receive 8-12 mCi of I-123 MIBG [metaiodobenzylguanidine]. The dose was delivered late to the Nuclear Medicine clinic and fell below the prescribed dosage range. The Nuclear Medicine OIC [Officer-in-Charge] changed the prescribed dosage from 8-12 mCi to 7-12 mCi, and the patient was subsequently dosed with 7.81 mCi. The procedure was successful and did not result in any medical/health impact or further need to repeat the study. [The Nuclear Medicine OIC] is currently not an authorized user (AU) on USAF Radioactive Material Permit No. CA-07840-03/07 AFP; therefore, he does not have the authority to adjust the prescribed dosage range. It is worth noting that [the Nuclear Medicine OIC] meets all the requirements to be an AU, and a request to add him was included with our pending permit renewal application provided to the Radioisotope Committee Secretariat (RICS) (USAF Licensee). Location: Travis AFB, David Grant USAF Medical Center 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 50692 +/-
Where
Air Force Medical Support Agency Travis Afb, California (NRC Region 4)
License number:	42-23539-01/A
Organization:	Air Force Medical Support Agency
Reporting

10 CFR 35.3045(a)(1)
Time - Person (Reporting Time:+34.95 h1.456 days <br />0.208 weeks <br />0.0479 months <br />)
Opened:	Daniel Shaw 12:57 Dec 18, 2014
NRC Officer:	Dong Park
Last Updated:	Dec 18, 2014
50692 - NRC Website
v • d • e

v t e Emergency Notification System
Air Force Medical Support Agency with 10 CFR 35.3045(a)(1)
WEEKMONTHYEAR2014-12-17T02:00:00 [Table view]
[ENS list for Air Force Medical Support Agency]

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