This is a notification, pursuant to
10 CFR 35.3045(a)(1), of a medical event that occurred at the
VA Medical Center, Durham,
North Carolina.
On December 29, 2014, a dosage of 1.569 millicuries of I-131 sodium iodide was administered to a patient for a diagnostic whole body scan, and the prescribed dosage on the written directive was 2 millicuries.
The basis for identifying this as a medical event is that the administered dosage differed from the prescribed dosage by more than 20 percent and the absorbed dose is estimated to differ from that dose that would have resulted from the prescribed dose by more than 50 rem to remnant thyroid tissue.
The medical event was discovered today (February 19, 2015) during a routine audit by the facility Radiation Safety Officer. The facility has notified the referring physician and the patient of the medical event. No biological harm to the patient is expected from this under-dosing event.
The NHPP [National Health Physics Program] plans to perform a reactive inspection regarding the medical event within the next 10 working days. A 15-day written report for the medical event will be submitted to NRC Region III. National Health Physics Program notified NRC Region III (Patricia Pelke, Chief, Materials Licensing Branch Chief) of the medical event by telephone.
Additional information: The Department of Veterans Affairs holds NRC License No. 03-23853-01VA, a master materials license. Permits are issued under the license to Veterans Health Administration facilities. The VHA permit number for the facility involved in this medical event is 32-01134-01. National Health Physics Program makes required notifications to NRC."
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.