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The following report was received from the … The following report was received from the State of North Carolina via email:</br>This is to notify you about a medical event under the regulation .0364, i.e., within 24-hr notification requirement after discovery. The following summarizes the medical event.</br>Event: Contamination of I-123 thyroid imaging dose with I-131 (WRONG RADIONUCLIDE). </br>Dose: 380 rad (3.8 Gy) to the thyroid gland (EXCEEDS 50-RAD THRESHOLD FOR ORGAN DOSE) </br>Notification: Patient's parent and referring physician have been notified. </br>A detailed report will follow within 15 days.</br>This event occurred sometime on Friday 11/13/10 and was discovered on Monday 11/15/10 at 1535 hrs. The patient was a child and potential adverse effects have not been determined at this time.</br>A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not</br>necessarily result in harm to the patient.</br>* * * UPDATE RECEIVED FROM PAUL HUGGINS TO JOHN SHOEMAKER VIA EMAIL ON 11/22/10 @ 0954 * * *</br>DESCRIPTION OF THE EVENT:</br>A patient was administered 0.389 mCi of iodine-123 orally for a thyroid uptake and scan procedure. Upon imaging at 4 hours, the technologist noted excessive background in the image. The acquisition computer showed an additional peak at 364 keV, consistent with presence of iodine-131 contamination. The iodine-131 thyroid burden at 21 hours was estimated to be about 43 microcuries. Based upon an iodine-123 uptake of 30%, the intake of iodine-131 was estimated to be about 143 microcuries. The absorbed dose to the thyroid, as estimated on 11/15/2010, was about 3.8 Gy (380 rad), or an equivalent dose of 3.8 Sv (380 rem), assuming age-specific reference values for thyroid mass and effective half-life. </br>An intake of 143 mCi of iodine-131 is comparable to activities that were administered in the past for diagnostic thyroid imaging, and no adverse effects are expected.</br>WHY THE EVENT OCCURRED:</br>Interviews with staff and assaying the equipment used for the iodine-123 administration indicate that the screw-cap on the vial was the likely source of the contamination. It is unclear whether the screw-cap removal device, or improper handling of the cap, was the cause of the contamination.</br>STEPS BEING TAKEN TO PREVENT A RECURRENCE:</br>The Authorized User and senior technical staff have educated staff about proper handling of radioiodine. To prevent a recurrence, we have changed our procedure as follows:</br>1) Only one radioiodine dose will be kept in the 'dosing hood' at any time.</br>2) The vial will be opened only when the patient and necessary staff are in the hot lab.</br>3) A separate cap remover will be used for each radionuclide.</br>4) Only one technologist will be involved with preparing dosing area, dosing the patient, cleaning up the dosing area and surveying post therapy.</br>North Caroline Incident #: NC 10-50</br>Notified R1DO - R. Conte and FSME - G. Villamar</br>* * * UPDATE FROM PAUL HUGGINS TO ERIC SIMPSON AT 0936 EST ON 12/2/10 * * *</br>The I-131 intake is being corrected to 143 microcuries, instead of 143 millicuries, as reported previously.</br>Notified the R1DO (Schmidt) and FSME (Villamar).ed the R1DO (Schmidt) and FSME (Villamar).
05:00:00, 13 November 2010 +
11:01:00, 16 November 2010 +
05:00:00, 13 November 2010 +
The following report was received from the … The following report was received from the State of North Carolina via email:</br>This is to notify you about a medical event under the regulation .0364, i.e., within 24-hr notification requirement after discovery. The following summarizes the medical event.</br>Event: Contamination of I-123 thyroid imaging dose with I-131 (WRONG RADIONUCLIDE). </br>Dose: 380 rad (3.8 Gy) to the thyroid gland (EXCEEDS 50-RAD THRESHOLD FOR ORGAN DOSE) </br>Notification: Patient's parent and referring physician have been notified. </br>A detailed report will follow within 15 days.</br>This event occurred sometime on Friday 11/13/10 and was discovered on Monday 11/15/10 at 1535 hrs. The patient was a child and potential adverse effects have not been determined at this time.</br>A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not</br>necessarily result in harm to the patient.</br>* * * UPDATE RECEIVED FROM PAUL HUGGINS TO JOHN SHOEMAKER VIA EMAIL ON 11/22/10 @ 0954 * * *</br>DESCRIPTION OF THE EVENT:</br>A patient was administered 0.389 mCi of iodine-123 orally for a thyroid uptake and scan procedure. Upon imaging at 4 hours, the technologist noted excessive background in the image. The acquisition computer showed an additional peak at 364 keV, consistent with presence of iodine-131 contamination. The iodine-131 thyroid burden at 21 hours was estimated to be about 43 microcuries. Based upon an iodine-123 uptake of 30%, the intake of iodine-131 was estimated to be about 143 microcuries. The absorbed dose to the thyroid, as estimated on 11/15/2010, was about 3.8 Gy (380 rad), or an equivalent dose of 3.8 Sv (380 rem), assuming age-specific reference values for thyroid mass and effective half-life. </br>An intake of 143 mCi of iodine-131 is comparable to activities that were administered in the past for diagnostic thyroid imaging, and no adverse effects are expected.</br>WHY THE EVENT OCCURRED:</br>Interviews with staff and assaying the equipment used for the iodine-123 administration indicate that the screw-cap on the vial was the likely source of the contamination. It is unclear whether the screw-cap removal device, or improper handling of the cap, was the cause of the contamination.</br>STEPS BEING TAKEN TO PREVENT A RECURRENCE:</br>The Authorized User and senior technical staff have educated staff about proper handling of radioiodine. To prevent a recurrence, we have changed our procedure as follows:</br>1) Only one radioiodine dose will be kept in the 'dosing hood' at any time.</br>2) The vial will be opened only when the patient and necessary staff are in the hot lab.</br>3) A separate cap remover will be used for each radionuclide.</br>4) Only one technologist will be involved with preparing dosing area, dosing the patient, cleaning up the dosing area and surveying post therapy.</br>North Caroline Incident #: NC 10-50</br>Notified R1DO - R. Conte and FSME - G. Villamar</br>* * * UPDATE FROM PAUL HUGGINS TO ERIC SIMPSON AT 0936 EST ON 12/2/10 * * *</br>The I-131 intake is being corrected to 143 microcuries, instead of 143 millicuries, as reported previously.</br>Notified the R1DO (Schmidt) and FSME (Villamar).ed the R1DO (Schmidt) and FSME (Villamar).
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00:00:00, 2 December 2010 +
032-0247-4 +
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02:08:18, 2 March 2018 +
11:01:00, 16 November 2010 +
3.251 d (78.02 hours, 0.464 weeks, 0.107 months) +
05:00:00, 13 November 2010 +
Agreement State Report - Patient Received a Thyroid Imaging Dose of I-123 That Was Contaminated with I-131 +
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