PNO-IV-98-018, on 980420,two Patients Were Misadministered Therapy Doses of P-32 by Radionuclide Synovectomy for Treatment of Arthritis.Caused by Misreading of Activity of Vial of P-32 Being Used to Calibrate Dose Calibrator
| ML20217C456 | |
| Person / Time | |
|---|---|
| Site: | 03014522 |
| Issue date: | 04/22/1998 |
| From: | Cain C, Spitzberg D NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV) |
| To: | |
| References | |
| PNO-IV-98-018, PNO-IV-98-18, NUDOCS 9804230319 | |
| Download: ML20217C456 (1) | |
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April 22,1998 PRELIMINARY NOTIFICATION OF EVENT OR UNUSUAL OCCURRENCE PNO-IV-98-018 This preliminary notification constitutes 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.
Facility Licensee Emeroency Classification Queens Medical Center Notification of Unusual Event Queens Medical Center Alert l Honolulu, Hawaii Site Area Emergency i License No: 53-16533-02 General Emergency X Not Applicable j
Subject:
MISADMINISTRATION OF THERAPEUTIC DOSES OF PHOSPHOROUS-32 l
The licensee reported that on April 20,1998, two patients were misadministered therapy doses of phosphorous-32 (P-32) by radionuclide synovectomy for treatment of arthritis. The
! administered doses of 3 millicurie (mci) to one patient and 1.5 mci to the other were 3 l l times the prescibed doses of 1 mci and 0.5 mCl, respectively. The licensee expects no adverse health effects to the patients and planned to notify the patients and referring ;
j physicians on April 21,1998.
l The preliminary cause of the misadministrations, as reported by the licensee, was the misreading of the activity of a vial of P-32 being used to calibrate the dose calibrator. The label on the vial, which contained 15 mci of P-32, was misread as 5 mci. This erroneous value was then used to determine the calibration factor for measuring the P-32 doses subsequently prepared. No other radiopharmaceutical doses were affected by this error.
l The State of Hawaii will be informed. Region IV will conduct a followup inspection at the
- licensee's facility.
1 Region IV received notification of this occurrence from the NRC Operations Center at 5:15 p.m. (CDT) on April 21,1998. Region IV has infonned NMSS.
l l This information has been discussed with the licensee and is current as of 6:30 p.m. (CDT),
April 21,1998.
Contact:
D. Blair SpitzbergCharles Cain (817)860-8191(817)860-8186
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/9 9004230319 900422 {\
h-I 8-018 PDR