PNO-III-86-145, on 861021,patient Given 1,530 Uci I-131 & Whole Body Scan Instead of 50-60 Uci I-131.Caused by Technician Misunderstanding Requisition.Region Will Inspect Hosp Prescription Procedure
| ML20211P091 | |
| Person / Time | |
|---|---|
| Site: | 03003425 |
| Issue date: | 12/12/1986 |
| From: | Axelson W, Sreniawski D NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | |
| References | |
| PNO-III-86-145, NUDOCS 8612180386 | |
| Download: ML20211P091 (1) | |
PRELIMINARY NOTIFICATION OF EVENT OR UNUSUAL OCCURRENCE--PNO-III-86-145 Date D:cember 12, 1986 DA6 This preliminary notification constitutes EARLY notice of events of POSSIBLE safety or public interest significance. The information is as initially received without v:rification or evaluation, and is basically all that is known by the Region II!
go W 475 staff on this date.-
Facility:
St. Luke's Memorial Hospital Licensee Emergency Classification:
Racine, Wisconsin Notification of an Unusual Event Alert License No. 48-02096-01 Site Area Emergency General Emergency X Not Applicable
Subject:
DIAGNOSTIC MISADMINISTRATION OF 10 DINE-131 On October 21, 1986, a patient scheduled to receive 50 to 60 microcuries of iodine-131 for a thyroid scan was erroneously given 1530 microcuries of iodine-131 and a whole-body scan.
The error apparently occurred when the administering technician misunderstood the requisition by the referring physician and radiologist.
The diagnostic procedure was ordered to evaluate a large mass next to the patient's thyroid gland. The licensee said the patient--as of December 5, 1986--had suffered no ill effects from the misadministration.
R;gion III (Chicago) will retain a medical consultant to review the event and the licensee's evaluation. Region III also will send an inspector to the hospital to review the licensee's prsscription procedures.
The State of Wisconsin will be notified.
R;gion III was notified of this event via a written report dated December 5, 1986, and received in the Region on December 9.
This information is current as of 9 a.m. (CST),
0;cember 12, 1986.
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Region III g21g86861212 Rev. November 1986 PNO-III-86-145 PDR