PNO-IV-88-010, on 880204,therapy Misadministration of P-32 Discovered.Physician Prescribed 4.0 Mci P-32 for Treatment of Polycythemia Vera (Excess Blood Platelets).Caused by Technologist Error.No Adverse Patient Effects Expected
| ML20149E013 | |
| Person / Time | |
|---|---|
| Site: | 03003233 |
| Issue date: | 02/05/1988 |
| From: | Cain C NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV) |
| To: | |
| References | |
| PNO-IV-88-010, PNO-IV-88-10, NUDOCS 8802100169 | |
| Download: ML20149E013 (1) | |
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February 5, 1988 PRELIMINARY NOTIFICATION OF EVENT OR UNUSUAL OCCURRENCE -- PNO-IV-88-10 -
This preliminary notification constitutes EARLY notice of events of POSSIBLE i
safety or public interest significance. The information is as initially received without verification or evaluation, and is basically all that is known by the Region IV staff en this date.
FACILITY: Medical X-Ray Center, P.C. Licensee Emergency Classification:
1417 South Minnesota Avenue Notification of Unusual Event Sioux Falls, South Dakota Alert LN 40-01493-02 Site Area Emergency General Emergency X Not Applicable
SUBJECT:
THERAPY MISADMINISTRATION OF PHOSPHORUS-32 The licensee reported a therapy misadministration which occurred at 3:00 p.m. on February 4, 1988. The licensee representative stated that the physician prescribed 4.0 millicuries of P-32 as sodium phosphate for treatment of
-polycythemia vera (excess blood platelets). The. technologist misread the physician's writte.; prescription and administered 7.5 millicuries. The referring physician and patient have been informed. The licensee stated that no adverse patient effects are expected.
Neither the licensee nor the NRC has issued a press release or informed the news media. Neither the licensee nor the NRC plans to issue a press release.
The state of South Dakota has been informed.
e
- Region IV received notification of this occurrence by telephone from the j licensee at 10
- 30 a.m. CST. Region IV has informed NMSS.
CONTACT: C. L. Cain, FTS 728-8186.
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9pRIf{y;0RSS RA Transmitted via 5520 2/5/88 A RLungart:cd RDMartin @11:35 a.m.
2/Q88 2/[/88 8802100169 800205-PDR I&E N PNO-IV-08-010 PDR