ENS 51894

v t e ENS Event
07:00 Apr 29, 2016
Title	Agreement State Report - Medical Misadministration
Event Description	The following was received from Arizona via email: On April 29th, the licensee [Tucson Medical Center] discovered that a patient had received 37 percent more than the prescribed dose of Xofigo (Radium-223). The licensee had received two doses of Ra-223 for two patients the day prior. The technologist usually asks a patient their weight in order to re-calculate the dose, but forgot and accidently grabbed another Xofigo patient's dose on April 28th. The technologist realized the mistake when she went to inject the second patient on the 29th and the name on the patient's dose did not match the current patient's name. The prescribed dose was 86.7 microcuries and the actual administered dose was 119.3 microcuries. The investigation into this event is ongoing. The U.S. NRC and Arizona Governor's office are being notified of this event." Arizona Incident # 16-008 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 51894 +/-
Where
Tucson Medical Center Tucson, Arizona (NRC Region 4)
License number:	AZ 10-010
Organization:	Arizona Radiation Regulatory Agency
Reporting

Agreement State
Time - Person (Reporting Time:+31.52 h1.313 days <br />0.188 weeks <br />0.0432 months <br />)
Opened:	Brian Goretzki 14:31 Apr 30, 2016
NRC Officer:	Daniel Mills
Last Updated:	Apr 30, 2016
51894 - NRC Website
v • d • e

v t e Emergency Notification System
Tucson Medical Center with Agreement State
WEEKMONTHYEAR2016-04-29T07:00:00 [Table view]
[ENS list for Tucson Medical Center]

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