ENS 44941: Difference between revisions
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| event date = 03/27/2009 EDT | | event date = 03/27/2009 EDT | ||
| last update date = 03/27/2009 | | last update date = 03/27/2009 | ||
| title = Missed Confirmations Led | | title = Missed Confirmations Led to Patient Receiving a Higher Dose | ||
| event text = A patient was prescribed a 12 millicurie dose of I-131 for treatment. When the hospital requested the dose from the pharmacy, a 15 millicurie dose was mistakenly requested. The dose requested was not confirmed against the prescribed dose. | | event text = A patient was prescribed a 12 millicurie dose of I-131 for treatment. When the hospital requested the dose from the pharmacy, a 15 millicurie dose was mistakenly requested. The dose requested was not confirmed against the prescribed dose. | ||
When the patient came in for treatment, the technologist preparing the dose measured a 15.5 millicurie dose but did not realize or confirm that this dose differed from the 12 millicurie prescribed dose. The 15.5 millicurie dose was administered instead of a 12 millicurie dose resulting in a dose to the patient of more than a 20% difference from the prescribed dose. The licensee will inform the patient of the higher dose. | When the patient came in for treatment, the technologist preparing the dose measured a 15.5 millicurie dose but did not realize or confirm that this dose differed from the 12 millicurie prescribed dose. The 15.5 millicurie dose was administered instead of a 12 millicurie dose resulting in a dose to the patient of more than a 20% difference from the prescribed dose. The licensee will inform the patient of the higher dose. | ||
Latest revision as of 21:12, 1 March 2018
| Where | |
|---|---|
| Regional Medical Imaging - Flint Flint, Michigan (NRC Region 3) | |
| License number: | 21-26076-01 |
| Organization: | Medical Physics Consultants |
| Reporting | |
| 10 CFR 35.3045(a)(1) | |
| Time - Person (Reporting Time:+8.5 h0.354 days <br />0.0506 weeks <br />0.0116 months <br />) | |
| Opened: | Laura Luna 12:30 Mar 27, 2009 |
| NRC Officer: | Pete Snyder |
| Last Updated: | Mar 27, 2009 |
| 44941 - NRC Website | |