ENS 55585
ENS Event | |
|---|---|
08:00 Jul 13, 2021 | |
| Title | Medical Event - Dose Above the Prescribed Dose |
| Event Description | The following was received from the licensee via email:
The VA National Health Physics Program is reporting a medical event as defined in 10 CFR 35.3045. The medical event occurred at the VA San Diego Healthcare System, San Diego, California. The Department of Veterans Affairs holds NRC license number 03-23853-01VA. The medical event occurred on July 13, 2021, and was discovered on November 16, 2021. The medical event involved the administration of approximately 152 millicuries of Iodine-131 sodium iodide to a patient. The patient received close to the activity intended by the authorized user physician. However, there was an error on the written directive form - the activity prescribed by the authorized user physician was mistakenly listed as 2 millicuries. Because the patient received the intended treatment, this medical event is not expected to cause any harm to the patient. The VA National Health Physics program has notified the NRC Project Manager for the VA Master Materials license. 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.
The following information was provided by the licensee via email: The VA National Health Physics Program is retracting an event that was previously reported as a possible medical event. It was reported to the NRC Operations Center on November 17, 2021, pursuant to 10 CFR 35.3045, NRC Event 55585. The event occurred at the VA San Diego Healthcare System, San Diego, California. The Department of Veterans Affairs holds NRC license number 03-23853-01VA. The event occurred on July 13, 2021. It was discovered on November 16, 2021. The event involved the administration of approximately 152 millicuries of iodine-131 sodium iodide to a patient. There was an error on a form labelled `written directive' - the activity prescribed by the authorized user physician was mistakenly listed as 2 millicuries. There was a second document: the patient medical order, which met the NRC criteria for a written directive, listed a prescribed dosage of 150 millicuries, was signed by the authorized user, and was used by the authorized user as the written directive. The basis for this retraction is, this was determined to be a paperwork error only; therefore, a medical event did not occur. Because the patient received the intended treatment, there was no harm to the patient. The facility has taken corrective actions to prevent a recurrence. The VA National Health Physics program has notified the NRC Project Manager for the VA Master Materials license of our plan to retract the event declaration. Notified R3DO (Stoedter) and NMSS Events Notification (email). |
| Where | |
|---|---|
| Us Department Of Veteran Affairs San Diego, California (NRC Region 3) | |
| License number: | 03-23853-01VA |
| Organization: | Va San Diego Healthcare System |
| Reporting | |
| 10 CFR 35.3045(a)(1) | |
| Time - Person (Reporting Time:+3053.78 h127.241 days <br />18.177 weeks <br />4.183 months <br />) | |
| Opened: | Joseph Bravenec 14:47 Nov 17, 2021 |
| NRC Officer: | Thomas Herrity |
| Last Updated: | Apr 25, 2023 |
| 55585 - NRC Website | |
Us Department Of Veteran Affairs with 10 CFR 35.3045(a)(1) | |
WEEKMONTHYEARENS 553532021-07-14T14:45:00014 July 2021 14:45:00
[Table view]10 CFR 35.3045(a)(1) Medical Event - Under Dose ENS 555852021-07-13T08:00:00013 July 2021 08:00:00 10 CFR 35.3045(a)(1) Medical Event - Dose Above the Prescribed Dose 2021-07-14T14:45:00 | |