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Start date | Reporting criterion | Title | Event description | System | LER | |
---|---|---|---|---|---|---|
ENS 41236 | 1 December 2004 16:00:00 | 10 CFR 35.3045(a)(1) | Medical Event - Greater than Perscribed Dose to an Organ | At 1100 EST on 12/01/04 a patient was to receive 4.5 milliCuries Thallium - 201 (Tl-201) and then 3 millicuries Technitium-99M (Tc-99M). The first dose was administered but instead of administering the technetium, a second dose of Thallium was administered. The patient and physician were informed. No adverse affects are expected. The hospital is conducting an investigation as to the cause of the improper administration.
After consulting with NRC Region 1, the licensee determined that this is not a reportable event because Thallium is not an NRC regulated isotope. Notified R1DO (Trapp) and NMSS (Janosko). |