ENS 52284

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v t e ENS Event
07:00 Sep 26, 2014
Title	Prescribed Dosage Incorrectly Written
Event Description	{{#Wiki_filter:This is a notification, pursuant to 10 CFR 35.3045(a)(1), of a medical event that occurred on September 26, 2014, at the VA Palo Alto Health Care System, Palo Alto, California. On September 26, 2014, a dosage of about 110 microCuries (�Ci) of radium-223 dichloride was administered to a patient. The prescribed dosage on the written directive was incorrectly written by the authorized user physician as 113.8 milliCuries (mCi). The basis for identifying this as a medical event is that the administered dosage differed from the prescribed dosage, as written on the written directive, by more than 20 percent. The authorized user physician was interviewed and stated that the intended prescription for injection was 113.8 �Ci of radium-223 dichloride. Another authorized user physician, the Chief, Nuclear Medicine Service, who administered the dosage, confirmed that this was an appropriate dosage for this patient. No harm to the patient is expected since the treatment was successfully performed with the administration of a dosage nearly identical to the intended dosage. The medical event was discovered October 5, 2016, during an unannounced inspection of this facility conducted by the National Health Physics Program (NHPP). The permittee is required to submit a written report to NHPP within 15 days of discovery. NHPP will, in turn submit the report to NRC per regulatory requirements. The NHPP inspection is ongoing to determine overall compliance with 10 CFR 35.40, 10 CFR 35.41, and 10 CFR 35.3045. 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 52284 +/-
Where
Va Palo Alto Health Care System Palo Alto, California (NRC Region 4)
License number:	03-23853-01VA
Organization:	Department Of Veterans Affairs
Reporting

10 CFR 35.3045(a)(1)
Time - Person (Reporting Time:+17793.1 h741.379 days <br />105.911 weeks <br />24.373 months <br />)
Opened:	Craig Adams 16:06 Oct 6, 2016
NRC Officer:	Dong Park
Last Updated:	Oct 6, 2016
52284 - NRC Website
v • d • e

v t e Emergency Notification System
Va Palo Alto Health Care System with 10 CFR 35.3045(a)(1)
WEEKMONTHYEAR2014-09-26T07:00:00 [Table view]
[ENS list for Va Palo Alto Health Care System]

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