ENS 52500
ENS Event | |
|---|---|
18:00 Jan 19, 2017 | |
| Title | Agreement State Report - Incorrect Drug Delivered to Patient |
| Event Description | The following was received via E-mail:
The North Carolina Radioactive Materials Branch (RMB) is submitting a report of a possible Medical Event reportable under 10 CFR 35.3045(a)(2)(i). Specifically, a dose was delivered to a patient with an effective dose equivalent (50 rem) to an organ through the administration of a wrong radioactive drug containing byproduct material. The RMB received the report of the possible Medical Event on 1/19/2017. NC Licensee Duke University, License 0247-4, reported to the RMB that around 1300 EST on 1/19/2017 a patient scheduled for a thyroid uptake scan in the Diagnostic Nuclear Medicine Department was incorrectly identified and received an oral dose of 2.0 mCi of Iodine-123 instead of the intended dose of 5-12 microCi of Iodine-131. An investigation was held on 1/20/2017 with members of Duke University to include the individual that delivered the incorrect dose to the patient. Following a review of the licensee's current procedures, it was noted that there is a minimum of two methods of patient verification prior to the administration of any diagnostic radioactive drug to any patient. An interview was conducted with the CNMT [Certified Nuclear Medicine Technologist] that delivered the incorrect dose and they freely admitted to not following the proper protocol which consists of confirming the Name and Date of Birth of the patient. Other factors may have attributed to this misadministration to include the volume of patients being treated that day and that there were two patients present that day with very similar first and last names. The patient with the similar name received the proper dose for their procedure. Following interviews with Duke personnel, it was determined that the CNMT received the proper training to adhere to this two factor authentication as dictated by internal procedures and was authorized under an approved AU for such uses. At this time, it appears the cause for this misadministration is due to human error. This investigation is ongoing and more details are to follow to update this report. Several records were requested of the licensee to include a dose assessment to verify the EDE of 50 rem or any excess of 50 rem delivered to the organ. The licensee is compiling it's 15 Day Report and will be providing it to the RMB as required by the Rule. Following receipt of that report, this event will be updated. 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 | |
|---|---|
| Duke University Durham, North Carolina (NRC Region 1) | |
| License number: | 0247-4 |
| Organization: | Nc Div Of Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+21.07 h0.878 days <br />0.125 weeks <br />0.0289 months <br />) | |
| Opened: | Travis Cartoski 15:04 Jan 20, 2017 |
| NRC Officer: | Steven Vitto |
| Last Updated: | Jan 20, 2017 |
| 52500 - NRC Website | |
Duke University with Agreement State | |
WEEKMONTHYEARENS 525602017-02-11T05:00:00011 February 2017 05:00:00
[Table view]Agreement State Agreement State Report - Leaking Uranium-235 Source with Contamination in Public Areas ENS 525002017-01-19T18:00:00019 January 2017 18:00:00 Agreement State Agreement State Report - Incorrect Drug Delivered to Patient ENS 452262009-07-15T04:00:00015 July 2009 04:00:00 Agreement State Agreement State Report Involving the Loss of a Californium-252 Source ENS 428382006-09-11T10:30:00011 September 2006 10:30:00 Agreement State Agreement State Report - Fire in a Laboratory Containing Nuclear Materials 2017-02-11T05:00:00 | |