ENS Event | |
|---|---|
06:00 Jul 13, 2016 | |
| Title | Agreement State Report - Misadministration During a Thyroid Ablation Procedure |
| Event Description | The following was reported by the Colorado Department of Health Radioactive Materials Unit via email:
CDPHE [Colorado Department of Public Health and Environment] became aware of the misadministration on the morning of Monday August 22, 2016. The event was reported to CDPHE on Friday August 19, 2016 at approximately 1630 [CDT] via a message that was left on an office voicemail inbox. The misadministration occurred during a thyroid ablation procedure on July 13, 2016. The prescribed dose was 75 milliCuries of I-131, and 78 milliCuries was delivered to the patient. The patient became aware that she was pregnant at the time of the procedure and notified St. Mary's Hospital and Medical Center on Tuesday, August 16, 2016. The gestation at time of procedure was estimated to be 9 days post conception. The Hospital's RSO reported an estimated dose to fetus of approximately 20 centiGray. The patient was given a pregnancy test prior to the procedure and the test results were negative. The licensee is claiming the misadministration was a result of patient non-compliance because the patient was instructed not to have sexual contact prior to the procedure. A written report from the licensee is pending; and will be followed-up by a formal investigation. Colorado Event Identification Number: CO16-I16-17 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 | |
|---|---|
| St. Mary'S Hospital And Medical Center Grand Junction, Colorado (NRC Region 4) | |
| License number: | CO 014-03 |
| Organization: | Colorado Dept Of Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+970.98 h40.458 days <br />5.78 weeks <br />1.33 months <br />) | |
| Opened: | Derek Bailey 16:59 Aug 22, 2016 |
| NRC Officer: | Jeff Herrera |
| Last Updated: | Aug 22, 2016 |
| 52193 - NRC Website | |
St. Mary'S Hospital And Medical Center with Agreement State | |
WEEKMONTHYEARENS 521932016-07-13T06:00:00013 July 2016 06:00:00
[Table view]Agreement State Agreement State Report - Misadministration During a Thyroid Ablation Procedure ENS 494312013-10-10T06:00:00010 October 2013 06:00:00 Agreement State Agreement State Report - Potential Dose from Deceased Patient with Previously Administered Iodine-131 2016-07-13T06:00:00 | |