ENS 51992

v t e ENS Event
04:00 Jan 16, 2015
Title	Agreement State Report - Medical Underdose
Event Description	The following report was received via e-mail: Memorial Sloan-Kettering Cancer Center reported that a pediatric male patient only received 64.38 MBq (1.74 mCi) of I-124 labeled monoclonal 8H9 on 1/16/2015, instead of the prescribed 120.25 MBq (3.25 mCi). The patient had been diagnosed with pontine glioma. The incident occurred because the infusion process along the gauze at the site of the catheter connector leaked. The leak was not obvious on visual inspection. The cause was determined to be a procedure problem. Corrective actions included generating a new procedure and improvements to radioactive material labeling and handling. NMED: 150094 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 51992 +/-
Where
Memorial Sloan Kettering Cancer Center New York City, New York (NRC Region 1)
License number:	NY-75-2968-01
Organization:	New York City Bureau Of Rad Health
Reporting

Agreement State
Time - Person (Reporting Time:+12227.53 h509.48 days <br />72.783 weeks <br />16.749 months <br />)
Opened:	Jose Lorenzo 14:32 Jun 8, 2016
NRC Officer:	Mark Abramovitz
Last Updated:	Jun 8, 2016
51992 - NRC Website
v • d • e

v t e Emergency Notification System
Memorial Sloan Kettering Cancer Center with Agreement State
WEEKMONTHYEAR2015-01-16T04:00:00 [Table view]
[ENS list for Memorial Sloan Kettering Cancer Center]

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