PNO-IV-96-071, on 961219,Region IV Walnut Creek Field Ofc Was Notified of Misadministration Involving Administration of I-131.Uptake Measurement Needed to Assist Authorized User in Determining Dosage Required to Treat Patient
| ML20132E159 | |
| Person / Time | |
|---|---|
| Site: | 03002935 |
| Issue date: | 12/20/1996 |
| From: | Linda Howell, Jonathan Montgomery NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV) |
| To: | |
| References | |
| PNO-IV-96-071, PNO-IV-96-71, NUDOCS 9612230090 | |
| Download: ML20132E159 (1) | |
. _. - - -
Decemb:r 20,1996 PRELIMINARY NOTIFICATION OF EVENT OR UNUSUAL OCCURRENCE PNO-IV-96-071 This preliminary notification conrtitutes EARLY notice of events of POSSIBLE safety or public interest significance. The information is as initially received without verification or evaluation, and is basically all that is known by Region IV staff in Arlington, Texas on this date.
E!a cility Licensee Emeraency Classification Department Of Veterans Affairs Notification of Unusual Event Va Medical Center Alert 3710 SW U.S. Veterans Hospital Road Site Area Emergency Portland, Oregon 97207 General Emergency Dockets: 03002935 License No: 36-01395-01 X Not Applicable
Subject:
SODIUM IODIDE l-131 MISADMINISTRATION On December 19,1996, the radiation safety officer (RSO) for the Veterans Administration Medical Center, Portland, Oregon, notified the Region IV Walnut Creek Field Office of a misadministration involving an administration of sodium iodide 1-131 (1-131). The RSO reported that on December 18,1996, an authorized user intended to prescribe a thyroid uptake dose of 10-15 microcuries of I-131 to a 63 year old male patient. The uptake measurement was needed to assist the authorized user in determining the dosage required to treat the patient's hyperthyroid condition. During verbal discussions with the authorized user about the patient and intended dose for the uptake study, a nuclear medicine technologist misinterp eted the authorized user's instructions and subsequently administered 300 microcuries of I-131 to the patient. No written directive was prepared for the uptake study because the authorized user intended to administer a dosage of less than 30 microcuries.
Region IV plans to obtain additional infrumation from licensee representatives when they are available on December 20. The region will perform an inspection to review this event.
The state of Oregon and NMSS have beers informed.
Region IV received notification of this occurrence by telephone from the licensee's Radiation Safety Officer (RSO) at 3:00 p.m., PST, on December 19,1996. Just prior to calling Region IV, the RSO notified the NRC Headquarters Operations Officer.
This information herein has been discussed with the licensee and is current as of 4:30 p.m.,
PST, December 19,1996.
Contact:
Jim Montgomery Linda Howell (510)975-0249 (817)860-8213 9612230090 PDR I&E 961220 PNO-IV-96-071 PDR [g3p o/t