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Start date | Reporting criterion | Title | Event description | System | LER | |
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ENS 44105 | 28 March 2008 17:00:00 | Information Only | Unplanned Dose to Fetus | A written directive was completed on 3/18/08 prescribing 18 mCi of I-131 (capsule) for the treatment of hyperthyroidism on 3/28/08. The (prescribing physician) indicated on the form that pregnancy test was negative and she was not breastfeeding. The pregnancy test result was attached to the directive. Upon arrival the patient completed an assessment form and consent form and she indicated in writing that she was not pregnant or breastfeeding. Staff and authorized user verified patient identity (name and birth date), dose, dose calibrator setting, and route of administration. The patient received the dose as prescribed. Nuclear Medicine was contacted by the lab shortly after the administration with a positive pregnancy result that was done on the day of the therapy. The patient's physician was notified. The patient was notified to increase fluids and void frequently and advised to make an appointment with her OBGYN physician. (A) Health Physicist Consultant was also notified and (the hospital) is awaiting the dose calculation to the embryo. At the time of the report, the hospital had not calculated a dose to the unborn child. The hospital will provide the calculated dose when it is available but the Radiation Safety Officer believes that the result will be less than 50 milliSieverts (< 5 rem). |