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The following information was provided by … The following information was provided by the Georgia Radioactive Materials Program via email:</br>Licensee contact stated the following: On March 12, 2025, a 71-year-old female patient received an administration of 1.98 millicuries (mCi) of sodium iodide I-123 for nuclear medicine thyroid imaging with uptake. The standard prescribed dose for this study is approximately 200 microcuries. Initial dose calculations, based on the package insert and a measured thyroid uptake of 64.7 percent, estimate the absorbed thyroid dose to be 1.67 Gy (167 rad). These calculations assume administration occurred near the end of the drug's expiration period. Further clarification regarding the exact dosing time will assist in refining the thyroid dose assessment.</br>An investigation is ongoing to determine the source of this dosing discrepancy. A formal written report will be submitted by the licensee on Friday, March 28, 2025.</br>GA NMED Report Incident #92</br>* * * UPDATE ON 03/31/2025 AT 1551 EDT FROM ANASTASIA BENNETT TO KERBY SCALES * * *</br>The following update is a summary of information received from the Georgia Radioactive Materials Program via email:</br>A patient was supposed to receive 200 microcuries of iodine-123 but instead received 1.98 mCi for a thyroid imaging study. The administered dose was approximately ten times higher than intended. This error resulted from miscommunication and mislabeling of the dose. The authorized user assessed the situation and determined that the risk of thyroid harm was minimal. The hospital calculated the thyroid dose to be approximately 1.74 Gy (174 rad) and has since implemented new safety measures. These include requiring faxed orders for radiopharmaceuticals and instituting multiple reviews for dose inspections to prevent future errors.</br>Notified R1DO (Bickett), NMSS Coordinator (Allen), NMSS (Silberfeld) and NMSS Events_Notification (email).</br>* * * UPDATE ON 04/03/2025 AT 1033 EDT FROM ANASTASIA BENNETT TO JORDAN WINGATE * * *</br>The following update is a summary of information received from the Georgia Radioactive Materials Program via email:</br>On April 2, 2025, a phone call was made to the radiation safety officer (RSO) for further clarification. The error originated from an incorrect recording of the dose units by the nuclear technician. The misrecorded information was then relayed to RLS Radiopharmacies, resulting in a labeling discrepancy. The technician did not verify or cross-check the recorded units before confirming the prescribed dose. The licensee is working to acquire an electronic tracking system like Epic within the next two months to ensure that miscommunications are limited. The radiation safety officer submitted a follow-up email to provide further clarification.</br>Notified R1DO (Bickett), NMSS Coordinator (Allen), NMSS (Silberfeld) and NMSS Events_Notification (email).</br>A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.necessarily result in harm to the patient.
04:00:00, 12 March 2025 +
57,624 +
16:10:00, 25 March 2025 +
04:00:00, 12 March 2025 +
The following information was provided by … The following information was provided by the Georgia Radioactive Materials Program via email:</br>Licensee contact stated the following: On March 12, 2025, a 71-year-old female patient received an administration of 1.98 millicuries (mCi) of sodium iodide I-123 for nuclear medicine thyroid imaging with uptake. The standard prescribed dose for this study is approximately 200 microcuries. Initial dose calculations, based on the package insert and a measured thyroid uptake of 64.7 percent, estimate the absorbed thyroid dose to be 1.67 Gy (167 rad). These calculations assume administration occurred near the end of the drug's expiration period. Further clarification regarding the exact dosing time will assist in refining the thyroid dose assessment.</br>An investigation is ongoing to determine the source of this dosing discrepancy. A formal written report will be submitted by the licensee on Friday, March 28, 2025.</br>GA NMED Report Incident #92</br>* * * UPDATE ON 03/31/2025 AT 1551 EDT FROM ANASTASIA BENNETT TO KERBY SCALES * * *</br>The following update is a summary of information received from the Georgia Radioactive Materials Program via email:</br>A patient was supposed to receive 200 microcuries of iodine-123 but instead received 1.98 mCi for a thyroid imaging study. The administered dose was approximately ten times higher than intended. This error resulted from miscommunication and mislabeling of the dose. The authorized user assessed the situation and determined that the risk of thyroid harm was minimal. The hospital calculated the thyroid dose to be approximately 1.74 Gy (174 rad) and has since implemented new safety measures. These include requiring faxed orders for radiopharmaceuticals and instituting multiple reviews for dose inspections to prevent future errors.</br>Notified R1DO (Bickett), NMSS Coordinator (Allen), NMSS (Silberfeld) and NMSS Events_Notification (email).</br>* * * UPDATE ON 04/03/2025 AT 1033 EDT FROM ANASTASIA BENNETT TO JORDAN WINGATE * * *</br>The following update is a summary of information received from the Georgia Radioactive Materials Program via email:</br>On April 2, 2025, a phone call was made to the radiation safety officer (RSO) for further clarification. The error originated from an incorrect recording of the dose units by the nuclear technician. The misrecorded information was then relayed to RLS Radiopharmacies, resulting in a labeling discrepancy. The technician did not verify or cross-check the recorded units before confirming the prescribed dose. The licensee is working to acquire an electronic tracking system like Epic within the next two months to ensure that miscommunications are limited. The radiation safety officer submitted a follow-up email to provide further clarification.</br>Notified R1DO (Bickett), NMSS Coordinator (Allen), NMSS (Silberfeld) and NMSS Events_Notification (email).</br>A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.necessarily result in harm to the patient.
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I-123 + and Iodine-123 +
00:00:00, 3 April 2025 +
GA 206-1 +
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11:20:04, 4 April 2025 +
16:10:00, 25 March 2025 +
13.507 d (324.17 hours, 1.93 weeks, 0.444 months) +
04:00:00, 12 March 2025 +
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