ENS 54143

v t e ENS Event
04:00 Jul 1, 2019
Title	Agreement State Report - Patient Underdose
Event Description	The following was received via email: On 7/2/2019, the Ohio Department of Health received a phone call from Nationwide Children's Hospital reporting a medical event. The licensee was treating acute myeloid leukemia (AML) with I-131 Iomab using a delivery system that is currently under research and development. The licensee stated the delivery system does not allow the dose vial to be seen and requires the manufacturer to set the infusion time. After the infusion, the technicians discovered the delivery system did not deliver the entire dose to the patient, resulting in an underdose of 42 percent. The patient and referring physician have been notified. An investigation of the event is pending. Ohio Item Number: OH190010 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 54143 +/-
Where
Nationwide Children'S Hospital Columbus, Ohio (NRC Region 3)
License number:	02110250002
Organization:	Ohio Bureau Of Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+55.8 h2.325 days <br />0.332 weeks <br />0.0764 months <br />)
Opened:	Michael Rubadue 11:48 Jul 3, 2019
NRC Officer:	Andrew Waugh
Last Updated:	Jul 3, 2019
54143 - NRC Website
v • d • e

v t e Emergency Notification System
Nationwide Children'S Hospital with Agreement State
WEEKMONTHYEAR2019-07-01T04:00:00 [Table view]
[ENS list for Nationwide Children'S Hospital]

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