ENS 53836
ENS Event | |
|---|---|
06:00 Jan 18, 2019 | |
| Title | En Revision Imported Date 2/22/2019 |
| Event Description | EN Revision Text: AGREEMENT STATE REPORT - MISADMINISTRATION OF RADIUM-223 TO PATIENT
The following was received via e-mail: On January 18, 2019, the Texas Department of State Health Services was contacted by the licensee's radiation safety officer (RSO) and notified that they had a treatment error occur at their facility. The error occurred to a patient who was to be treated with multiple fractions of radium-223. The treatment was to relieve bone pain in the patient. The dose from each fraction was based on the weight of the patient. The fraction activity was determined to be 75 microCuries based on the weight in pounds of the patient involved. The technician involved with administering the dose mistook the weight units and ordered the fraction dose based on the patients weight measured in kilograms. As a result the patient was administered 165 microCuries of radium-223 instead of the 75 microCuries. The error was discovered as they were preparing to administer the second dose (The date of the first dose was not provided). The RSO stated the patient and prescribing physician have been contacted and notified of the error. The RSO stated the patient would not experience any adverse effects from the dose received. The RSO stated the patient's treatment going forward is being reviewed. The RSO stated they would provide a written report next week. At 1530 hours0.0177 days <br />0.425 hours <br />0.00253 weeks <br />5.82165e-4 months <br /> the Agency contacted the RSO and confirmed the dose to the patient. The RSO stated the dose to the bones from the activity given would be 693 rad instead of 315 rad. Additional information will be provided as it is received in accordance with SA-300. Texas Department of State Health Services Incident Number 9651
The following report was received via e-mail: This event was determined not to be a reportable event. It does not meet the reportability criteria. Dosage on the written directive, signed by the prescribing physician/authorized user, was the dosage administered to the patient. Notified the R4DO (Deese) and NMSS (via e-mail). 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 | |
|---|---|
| Texas Oncology Pa Dallas, Texas (NRC Region 4) | |
| License number: | L04878 |
| Organization: | Texas Dept Of State Health Services |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+10.82 h0.451 days <br />0.0644 weeks <br />0.0148 months <br />) | |
| Opened: | Art Tucker 16:49 Jan 18, 2019 |
| NRC Officer: | Jeffrey Whited |
| Last Updated: | Feb 21, 2019 |
| 53836 - NRC Website | |
Texas Oncology Pa with Agreement State | |
WEEKMONTHYEARENS 542312019-07-30T05:00:00030 July 2019 05:00:00
[Table view]Agreement State Agreement State Report - Incorrect Dosage Administered ENS 539322019-03-07T05:00:0007 March 2019 05:00:00 Agreement State Agreement State Report - Misadministration of Dose to Patient ENS 538362019-01-18T06:00:00018 January 2019 06:00:00 Agreement State En Revision Imported Date 2/22/2019 ENS 532262018-02-21T06:00:00021 February 2018 06:00:00 Agreement State Agreement State Report - Medical Event 2019-07-30T05:00:00 | |