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. |
| 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 | |
Holmes Regional Medical Center, Inc. with Agreement State | |
WEEKMONTHYEARENS 541152019-06-11T04:00:00011 June 2019 04:00:00
[Table view]Agreement State Agreement State Report - Patient Dosage Greater than Prescribed 2019-06-11T04:00:00 | |