Browse wiki
Jump to navigation
Jump to search
The following information was provided by … The following information was provided by the Kentucky Department for Public Health & Safety, Radiation Health Branch (KY RHB) via email:</br>KY RHB was notified on August 20, 2024, by a representative from Leonard Lawson Cancer Center (of the following:)</br>The date of discovery is August 20, 2024 at 13:30 EDT. There were two medical events for the same patient receiving Ra-223 dichloride. In each of the two cases, the patient was under dosed.</br>The authorized user physician and the patient have been notified of the medical events.</br>The first dose was administered on July 9, 2024, with a prescribed dose of 91.2 micro Ci and an administered dose of 72.46 micro Ci with a difference of 20.5 percent.</br>(The second dose is being tracked under a different NRC Event number. See EN 57276)</br>The written directive procedure is to measure the dose in the dose calibrator and then administer the dose. The medical physicians deviated from the written directive procedure and adjusted the dose based of the following calculation:</br>Volume to administered equals (Body weight in kg x 1.35 micro Ci/kg)/(decay factor x 27 micro Ci/ml).</br>The concentration provided in the formula is different than the concentration for each dose. The concentration for the first dose was 19.17 micro Ci/ml. Also, this formula was taken from an old Bayer document from 2013. The current Bayer document provides the following formula.</br>Volume to administered equals (Body weight in kg x 1.49 micro Ci/kg)/(decay factor x 30 micro Ci/ml).</br>The problem is the document does not instruct one to use an actual concentration for the patient specific dose.</br>The two reasons for the medical events are:</br>1) The medical physicist did not follow the written directive procedure. He added the volume calculation step.</br>2) The Bayer documentation does not instruct you to use the actual concentration for the patient specific dose.</br>The incident remains under evaluation and investigation for corrective actions.</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.not necessarily result in harm to the patient.
18:30:00, 20 August 2024 +
17:55:00, 20 August 2024 +
18:30:00, 20 August 2024 +
The following information was provided by … The following information was provided by the Kentucky Department for Public Health & Safety, Radiation Health Branch (KY RHB) via email:</br>KY RHB was notified on August 20, 2024, by a representative from Leonard Lawson Cancer Center (of the following:)</br>The date of discovery is August 20, 2024 at 13:30 EDT. There were two medical events for the same patient receiving Ra-223 dichloride. In each of the two cases, the patient was under dosed.</br>The authorized user physician and the patient have been notified of the medical events.</br>The first dose was administered on July 9, 2024, with a prescribed dose of 91.2 micro Ci and an administered dose of 72.46 micro Ci with a difference of 20.5 percent.</br>(The second dose is being tracked under a different NRC Event number. See EN 57276)</br>The written directive procedure is to measure the dose in the dose calibrator and then administer the dose. The medical physicians deviated from the written directive procedure and adjusted the dose based of the following calculation:</br>Volume to administered equals (Body weight in kg x 1.35 micro Ci/kg)/(decay factor x 27 micro Ci/ml).</br>The concentration provided in the formula is different than the concentration for each dose. The concentration for the first dose was 19.17 micro Ci/ml. Also, this formula was taken from an old Bayer document from 2013. The current Bayer document provides the following formula.</br>Volume to administered equals (Body weight in kg x 1.49 micro Ci/kg)/(decay factor x 30 micro Ci/ml).</br>The problem is the document does not instruct one to use an actual concentration for the patient specific dose.</br>The two reasons for the medical events are:</br>1) The medical physicist did not follow the written directive procedure. He added the volume calculation step.</br>2) The Bayer documentation does not instruct you to use the actual concentration for the patient specific dose.</br>The incident remains under evaluation and investigation for corrective actions.</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.not necessarily result in harm to the patient.
Has query"Has query" is a predefined property that represents meta information (in form of a <a rel="nofollow" class="external text" href="https://www.semantic-mediawiki.org/wiki/Subobject">subobject</a>) about individual queries and is provided by <a rel="nofollow" class="external text" href="https://www.semantic-mediawiki.org/wiki/Help:Special_properties">Semantic MediaWiki</a>.
00:00:00, 20 August 2024 +
202-375-27 +
Modification date"Modification date" is a predefined property that corresponds to the date of the last modification of a subject and is provided by <a rel="nofollow" class="external text" href="https://www.semantic-mediawiki.org/wiki/Help:Special_properties">Semantic MediaWiki</a>.
11:20:05, 28 August 2024 +
17:55:00, 20 August 2024 +
-0.0242 d (-0.58 hours, -0.00345 weeks, -7.94484e-4 months) +
18:30:00, 20 August 2024 +
URL"URL" is a <a href="/Special:Types/URL" title="Special:Types/URL">type</a> and predefined property provided by <a rel="nofollow" class="external text" href="https://www.semantic-mediawiki.org/wiki/Help:Special_properties">Semantic MediaWiki</a> to represent URI/URL values.