PNO-III-80-232, on 801218,11 Mci P-32 Administered to Patient Who Was Supposed to Receive I-131.Patient Stomach Pumped,But Only 0.5 Mci Retrieved.Six Doses of Amphogel Administered
| ML19343B937 | |
| Person / Time | |
|---|---|
| Issue date: | 12/19/1980 |
| From: | Paperiello C, Sreniawski D NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | |
| References | |
| PNO-III-80-232, NUDOCS 8102180324 | |
| Download: ML19343B937 (2) | |
,4 PRELIMINARY NOTiflCATION Date: December 19, 1980 PRELIMINARY NOTlflCATION Of EVENT OR UNUSUAL OCCURENCE--PNO-III-8 -232 Page 1 of 2 This preliminary notification constitutes ii4Y notice of events of POSSIBLE safety or public interest sianificance.
The information presented is as initially received without verification or evaluation and is basically all that is known by lE staff as of this date.
Farility: Mayo Clinic Rochester, MN License No.
22-00519-03
SUBJECT:
MISADMINISTRATION OF 11 MILLICURIES OF P-32 SODIUM PIIOSPilATE Region III (Chicago) received telephone notification of a misadministration of 11 mil 11 curies of P-32 labeled sodium phosphate.
The patient was a 72 year old female who was to receive 11 millicuries of I-131 for treatment of hyperthyroidism.
The P-32 was administered orally instead of the I-131 at approximately 12:30 p.m.
(CST) on December 18, 1980. At 1:30 p.m. the patient's stomach was pumped and approximately 0.5 millicurie was retrieved.
Six doses of Amphogel (an ion absorbtion agent), which could reduce the amount of P-32 absorbed by as much as half, were administered. A blood count was performed before the administration of the nuclide and will be repeated December 19, 1980.
The patient's personal physician has been notified.
Region III has contacted Dr. E. L. Saenger, M.D., who has conferred with the patient's physician.
Dr. Saenger indicated that the hospital's response, to date. has been appropriate.
Preliminary dose estimates assuming no uptake by the Amphegel agent indicates a target organ (bone) dose of 375-400 rem and a whole body dose of approximately 75 rem.
The Amphogel may reduce these to 200 rem and 40 rem respectively.
The State of Minnesota has been notified.
Region III does not anticipate issuing a press release at this time.
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PRELIMINARY NOTIFICATION 810218037f a
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O PRELit!INARY NOTIFICATION PSO-III 232 Page 2 of 2 l'
Date:
December 19, 1980 Two Region III inspectors are enroute to the Itayo Clinic.
Region III received the initial notification of this event at about 4:45 p.m.
(CST) on December 18, 1980, from the' licensees Radiation Safety Officer.
Headquarters duty office was notified at about 5:30 p.m. CST on December 18, 1980 and given the latest update at about 9:00 p.m. CST the same evening.
This information is current as of 7:30 a.m. CST, December 19, 1980.
Contact:
D. J.
Sreniawski, RIII 384-2513 C. J. Paperiello, RIII 384-2611 I
Distribution:
TransmittedIIStf4j Chairm.in Ahearne Commissioner llendric S. J. Chilk, SECY Commissioner Gilinsky Commissioner Bradford C. C. Kammerer, CA l
ACRS (For Distribution)
?!NBB[24 P. Bldg. g.ff IE:TAS[f[(IE:HQDist.)
Transmitted:
W. J. Dirchs, EDO II. R. Denton, NRR C. !!ichelson, AEOD R. II. Vollmer, NRR L. indow (6 min /page)
J. J. Fouchard, PA F. Schroeder, NRR J. J. Cummings, OlA l
N. ?!. !! aller, flPA D. F. Ross, NRR l
G. W. Kerr, OSP D. Eisenhut, NRR
!!AI L li. K. Shapar, ELD S. II. Ilanauer,NRR R. Smith, SD IE:TAS Region I
[3 Wi l l s t e illdg. [./ ' '
Document ligt. Br. (For PDR/LPD)
Region Il
'M J.G. Davis,Kri5h
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Region IV R. Itinogue, RES S. Ebbin, Executive Director g
Nuclear Safety Oversight Committee Region V 1133 15th Street NW, Suite 307 V shington, DC 20005 3
PRELI!!INARY NOTIFICATION