ENS 53925

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v t e ENS Event
04:00 Feb 13, 2019
Title	Agreement State Report - Underdosage to Patient During I-131 Treatment
Event Description	The following was received from the state of Pennsylvania: On 2/13/19, a patient was administered 171 milliCuries (mCi) of liquid iodine 131 (I-131) through a feeding tube inserted into the patient's gastric tube as he was unable to swallow I-131 in pill form. While flushing the feeding tube with saline, a technologist noticed a pool of liquid next to the patient on a disposable drape, on the patient, and on the imaging table, that was determined to be radioactive. The feeding tube was removed from the gastric tube, and flushed, without any further leaking. All non-essential personnel were cleared from the room and the nuclear medicine staff contained the spill, decontaminated the patient and the site. All radioactive trash was contained in a lead-lined storage drum and secured. No hospital personnel were contaminated during this event. The licensee reported that given the I-131 dose was diluted with saline, the total amount of I-131 that was spilled could not be determined at the time of the event. In an effort to determine the activity and dose the licensee surveyed all contaminated items in their storage drum. Using this data and conservative decay calculations the licensee estimates 97.2 mCi was spilled. This resulted in an under-dose of 56.8 percent. The patient is scheduled for another administration to complete the therapy. The DEP [Pennsylvania Department of Environmental Protection, Bureau of Radiation Protection] will update this event as soon as more information is provided. Pennsylvania Event Report Number: PA190007 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 53925 +/-
Where
St. Lukes Hospital - North Campus Bethlehem, Pennsylvania (NRC Region 1)
License number:	PA-0073
Organization:	Pa Bureau Of Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+631.28 h26.303 days <br />3.758 weeks <br />0.865 months <br />)
Opened:	John Chippo 10:17 Mar 11, 2019
NRC Officer:	Jeffrey Whited
Last Updated:	Mar 11, 2019
53925 - NRC Website
v • d • e

v t e Emergency Notification System
St. Lukes Hospital - North Campus with Agreement State
WEEKMONTHYEAR2019-02-13T04:00:00 [Table view]
[ENS list for St. Lukes Hospital - North Campus]

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