ENS Event | |
|---|---|
08:00 Jan 7, 2015 | |
| Title | Agreement State Report - Dose Administered Exceeded 50 Rem |
| Event Description | The following information was provided by the State of California Department of Public Health - Radiological Health Branch (RHB) via email:
On 01/14/15, RHB received an email from the RSO reporting a Medical Event. On 1/7/15 a patient was scheduled for a thyroid uptake scan. Instead of the prescribed dose of 300 microcuries of Sodium Iodide 123, 3.69 mCi [3690 microcuries] of the isotope was administered to the patient. Due to quality of the scan, the error was noted. An initial calculation performed on 1/8/15 indicated target organ [dose] exceeding 50 rem. On 1/9/14, another calculation performed by the consulting physicist using patient's actual measured uptake values, the target organ [dose] was deemed less than 50 rem and it was decided to be non-reportable. On 1/13/15, the chief of Nuclear Medicine reviewed the reference source and contacted the same physicist to review his calculations, and the physicist realized that he made an error in calculations, and informed the facility that the organ dose exceeded 50 rem. On 1/14/15, the Kaiser Medical Physicist confirmed the [dose] to be 53.6 rem to the thyroid, and the RSO notified RHB of the Medical Event. RHB will be following up on this matter." CA Event Report Number: 011415 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. |
| Where | |
|---|---|
| Kaiser Permanente Medical Center - Antioch Antioch, California (NRC Region 4) | |
| License number: | NOT PROVIDED |
| Organization: | California Radiation Control Prgm |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+199.6 h8.317 days <br />1.188 weeks <br />0.273 months <br />) | |
| Opened: | Kent Pendergast 15:36 Jan 15, 2015 |
| NRC Officer: | Jeff Herrera |
| Last Updated: | Jan 15, 2015 |
| 50738 - NRC Website | |
Kaiser Permanente Medical Center - Antioch with Agreement State | |
WEEKMONTHYEARENS 507382015-01-07T08:00:0007 January 2015 08:00:00
[Table view]Agreement State Agreement State Report - Dose Administered Exceeded 50 Rem 2015-01-07T08:00:00 | |