ENS Event | |
|---|---|
13:30 Aug 22, 2017 | |
| Title | Agreement State Report- Medical Event Misadministration |
| Event Description | This following report was phoned in, followed by an email:
On August 22, 2017, Chesapeake Urology, notified the Maryland Radiological Health Program (RHP) that a male patient was injected with 176.1 microCuries of Ra-223 (Xofigo) instead of 108.4 microCuries of Ra-223 (Xofigo); 62.5 percent greater than the prescribed dose. The wrong unit dose was handed to the authorized user for patient administration. The event occurred at approximately 0930 [EDT] hours on 08/22/2017 at the licensee's address of 21 Crossroads Drive, Suite 200, Owings Mills, MD 21117. Maryland RHP was notified by telephone at 1505 hours0.0174 days <br />0.418 hours <br />0.00249 weeks <br />5.726525e-4 months <br />. Two patients were scheduled for treatment on August 22, 2017. Both doses were assayed in the morning. Each dose had the proper patient name on the lead pig and on each respective syringe. The incorrect dose was selected and injected without cross referencing the identity of the patient. The event was discovered at approximately 1130 hours0.0131 days <br />0.314 hours <br />0.00187 weeks <br />4.29965e-4 months <br /> when the second Xofigo dose was to be administered. The patient and the referring physician have been informed of the misadministration. A written notification from the licensee is expected in about a week. This is a preliminary notification." 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 | |
|---|---|
| Chesapeake Urology Owings Mills, Maryland (NRC Region 1) | |
| License number: | MD-05-208-01 |
| Organization: | Maryland Dept Of The Environment |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+21.25 h0.885 days <br />0.126 weeks <br />0.0291 months <br />) | |
| Opened: | Allen Goldery 10:45 Aug 23, 2017 |
| NRC Officer: | Richard Smith |
| Last Updated: | Aug 23, 2017 |
| 52920 - NRC Website | |
Chesapeake Urology with Agreement State | |
WEEKMONTHYEARENS 529202017-08-22T13:30:00022 August 2017 13:30:00
[Table view]Agreement State Agreement State Report- Medical Event Misadministration 2017-08-22T13:30:00 | |