ENS 54132

v t e ENS Event
04:00 Jun 24, 2019
Title	Agreement State Report - Administered Dose Different than Prescribed
Event Description	The following was received from the North Carolina Radioactive Materials Branch via email: On 6/24/19, a patient underwent a Xofigo therapy treatment and did not receive the full dose as prescribed but had to return the following day to receive the full dose on 6/25/19. Due to the size of the patient and the fact that Xofigo doses typically arrive to the licensee in 10cc syringes, [in order] to accommodate the patient with the correct dose, the dose prescribed to the patient was split between two doses/syringes. On 6/24/19, licensee personnel delivered the first dose of 119.19 microCuries (Ra-223) which was approximately 50 percent of the prescribed dose. It was discovered after the patient was discharged that the remaining dose was still in the hot lab. The prescribing physician was immediately notified and the patient returned the following day, 6/25/19, and received the second dose of 114.5 microCuries (Ra-223). NC Radiation protection is currently investigation this incident and will follow up to close and complete this report." NC tracking number: 190021 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 54132 +/-
Where
Cone Health Wesley Long Hospital Greensboro, North Carolina (NRC Region 1)
License number:	041-0153-1
Organization:	Nc Div Of Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+59.75 h2.49 days <br />0.356 weeks <br />0.0818 months <br />)
Opened:	Travis Cartoski 15:45 Jun 26, 2019
NRC Officer:	Caty Nolan
Last Updated:	Jun 26, 2019
54132 - NRC Website
v • d • e

v t e Emergency Notification System
Cone Health Wesley Long Hospital with Agreement State
WEEKMONTHYEAR2019-06-24T04:00:00 [Table view]
[ENS list for Cone Health Wesley Long Hospital]

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