ENS 53847

v t e 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.

ENS 53847 +/-
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
v • d • e

v t e Emergency Notification System
Inspira Medical Centers, Inc. with Agreement State
WEEKMONTHYEAR2019-01-24T05:00:00 [Table view]
[ENS list for Inspira Medical Centers, Inc.]

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