ENS 55142

v t e ENS Event
05:00 Mar 11, 2021
Title	Dose Received Was Less than Prescribed Dose
Event Description	The following was received via an email from the state of North Carolina: Licensee reported that on March 11, 2021, a medical event occurred where the dose difference [from Iodine 131 is greater than 20 percent from the prescribed dosage]. The prescribed dosage (by written directive) was 949 milliCuries; but the administered dose is estimated at this time to be about 507 milliCuries, which is 53% of the prescribed dose. The cause was a leaking tube from the infusion system. The bone marrow dose needed by the patient was considered sufficient, so there was no negative impact to the patient. An investigation by the North Carolina Radioactive Materials Branch is ongoing at this time. The radiopharmaceutical administered was Iomab-B (Iodine-131). North Carolina Tracking Number: 210003. 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 55142 +/-
Where
Unc Hospitals Chapel Hill, North Carolina (NRC Region 1)
License number:	068-0565-1
Organization:	Nc Div Of Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+104.72 h4.363 days <br />0.623 weeks <br />0.143 months <br />)
Opened:	Ken Bugaj 12:43 Mar 15, 2021
NRC Officer:	Lloyd Desotell
Last Updated:	Mar 15, 2021
55142 - NRC Website
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