ENS 54115

v t e ENS Event
04:00 Jun 11, 2019
Title	Agreement State Report - Patient Dosage Greater than Prescribed
Event Description	The following report was received from the State of Florida Bureau of Radiation Control via email: This morning, HRMC Inc. [Holmes Regional Medical Center] called to report a misadministration of Y-90 TheraSpheres to a patient, 77 y/o female. Prescribed activity was 0.304 GBq, prescribed dose was 120 grey. Administered activity was 3.0 GBq, awaiting confirmation of administered dose, BRC [Bureau of Radiation Control] assumes administered dose will be 10 times prescribed dose based on 10 times administered activity. Lot # 1999265. An authorized physician discussed this incident with the patient and a few family members. This was intended to be a one time treatment. This appears to meet the criteria for an abnormal occurrence. Florida Incident Number: FL19-078 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 54115 +/-
Where
Holmes Regional Medical Center, Inc. Melbourne, Florida (NRC Region 1)
License number:	0545-2
Organization:	Florida Bureau Of Radiation Control
Reporting

Agreement State
Time - Person (Reporting Time:+35.75 h1.49 days <br />0.213 weeks <br />0.049 months <br />)
Opened:	Matthew G. Senison 15:45 Jun 12, 2019
NRC Officer:	Jeff Herrera
Last Updated:	Jun 12, 2019
54115 - NRC Website
v • d • e

v t e Emergency Notification System
Holmes Regional Medical Center, Inc. with Agreement State
WEEKMONTHYEAR2019-06-11T04:00:00 [Table view]
[ENS list for Holmes Regional Medical Center, Inc.]

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