ENS Event | |
|---|---|
05:00 Jan 24, 2019 | |
| Title | Agreement State Report - Patient Underdosed by Greater than 20 Percent |
| Event Description | The following was received from the State of New Jersey via email:
While a dosage of samarium-153 Quadramet was being administered to a patient, no one noticed that there was a crack in the locking assembly of the IV tubing connection. As a result, when the material was being administered, most of it leaked out of the assembly, rather than being administered to the patient. This resulted in the patient receiving only 2.35 mCi of the prescribed dosage of 58 mCi. This caused a reportable underdosage. The physician has been informed and all the necessary involved persons involved have been supplied with this information. The licensee will follow-up with a full report. 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 | |
|---|---|
| Inspira Medical Centers, Inc. Vineland, New Jersey (NRC Region 1) | |
| License number: | 450632 |
| Organization: | Nj Rad Prot And Rel Prevention Pgm |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+29.62 h1.234 days <br />0.176 weeks <br />0.0406 months <br />) | |
| Opened: | Richard Peros 10:37 Jan 25, 2019 |
| NRC Officer: | Thomas Kendzia |
| Last Updated: | Jan 25, 2019 |
| 53847 - NRC Website | |
Inspira Medical Centers, Inc. with Agreement State | |
WEEKMONTHYEARENS 538472019-01-24T05:00:00024 January 2019 05:00:00
[Table view]Agreement State Agreement State Report - Patient Underdosed by Greater than 20 Percent 2019-01-24T05:00:00 | |