ENS Event | |
|---|---|
05:00 Feb 16, 2017 | |
| Title | Agreement State Report - Administered Dose Lower than Prescribed Dose |
| Event Description | The following information was received from the Commonwealth of Kentucky via email:
Hardin Memorial Hospital (HMH) reported that a patient only received 106 mCi of I-131, instead of the prescribed 150 mCi post-thyroidectomy on 2/16/17. Two capsules of I-131 were received from the radiopharmacy in a single vial. When the technologist gave the patient the vial, the patient shook the contents of the vial into her mouth only swallowing one capsule. The tech did not see one capsule remained in the vial. Surveys on the package (containing the vial) that was to be sent back to the radiopharmacy were higher than background so [it] was held for decay. Another survey on 2/28/17 was taken and was still higher than background so the tech opened the package and discovered the remaining pill. Kentucky Event Report ID No.: KY170002 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 | |
|---|---|
| Hardin Memorial Hospital Elizabethtown, Kentucky (NRC Region 1) | |
| License number: | 202-029-22 |
| Organization: | Kentucky Dept Of Radiation Control |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+637.58 h26.566 days <br />3.795 weeks <br />0.873 months <br />) | |
| Opened: | Marissa Vega Velez 17:35 Mar 14, 2017 |
| NRC Officer: | Howie Crouch |
| Last Updated: | Mar 14, 2017 |
| 52611 - NRC Website | |
Hardin Memorial Hospital with Agreement State | |
WEEKMONTHYEARENS 535852018-09-07T04:00:0007 September 2018 04:00:00
[Table view]Agreement State Agreement State Report - Administered Dose Lower than Prescribed Dose ENS 526112017-02-16T05:00:00016 February 2017 05:00:00 Agreement State Agreement State Report - Administered Dose Lower than Prescribed Dose ENS 509342015-03-25T17:00:00025 March 2015 17:00:00 Agreement State Agreement State Report - Medical Event During Prostate Brachytherapy ENS 491972013-07-16T16:30:00016 July 2013 16:30:00 Agreement State Agreement State Report - Permanent Prostate Brachytherapy Underdose ENS 480862012-06-04T05:00:0004 June 2012 05:00:00 Agreement State Kentucky Agreement State Report - Medical Event Involving Prostate Seed Implants ENS 454852009-08-28T06:00:00028 August 2009 06:00:00 Agreement State Agreement State Report - Brachytherapy Patient Received More than Prescribed Dose 2018-09-07T04:00:00 | |