ENS 44461: Difference between revisions

From kanterella

Latest revision as of 21:13, 1 March 2018

v t e ENS Event
10:00 Jun 2, 2008
Title	Potential Misadministration Greater than 20% of Prescribed Dose
Event Description	The RSO performed a quarterly audit on 9/2/08 and discovered that a misadministration greater than 20% of prescribed dose and greater than 50 Rem to the lung tissue occurred on 6/2/08. The prescribed dose was 1.0 ml of P-32 chromic phosphate into two separate syringe applications. The technician prepared the first P-32 dose into syringe "A" and recorded into the written record after calibrated assay as 1.3 ml and performed the same procedure for the second dose which was recorded into the written record as 1.0 ml into syringe "B". The first dose in syringe "A" exceeded the allowable dose. Both syringe applications were given to the patient into separate lung tube injections. The prescribing physician and authorized user have been notified. It is not known if the patient has been notified. * * RETRACTION AT 1545 EDT ON 9/5/08 FROM OYTOMARI TO SANDIN * * * Based on further review of this event by the licensee, it was determined that the total dose to the lung was less than 50 Rem. As a result, the event does not meet reportability criteria under 10CFR35.3045. The licensee has reviewed its conclusion with NRC Region 4 inspectors (Whitten and Munoz). R4DO (Jones) and FSME (Turtil) have been notified.

ENS 44461 +/- *RETRACTED*
Where
Queens Medical Center Honolulu, Hawaii (NRC Region 4)
License number:	53-16533-02
Organization:	Queens Medical Center
Reporting

10 CFR 35.3045(a)(1)
Time - Person (Reporting Time:+2236.02 h93.168 days <br />13.31 weeks <br />3.063 months <br />)
Opened:	Brian Oytomari 14:01 Sep 3, 2008
NRC Officer:	Joe O'Hara
Last Updated:	Sep 5, 2008
44461 - NRC Website
v • d • e

v t e Emergency Notification System
Queens Medical Center with 10 CFR 35.3045(a)(1)
WEEKMONTHYEAR2008-06-02T10:00:00 [Table view]
[ENS list for Queens Medical Center]

@@ Line 17: / Line 17: @@
 | event date = 06/02/2008 HST
 | last update date = 09/05/2008
-| title = Potential Misadministration Greater Than 20% Of Prescribed Dose
+| title = Potential Misadministration Greater than 20% of Prescribed Dose
 | event text = The RSO performed a quarterly audit on 9/2/08 and discovered that a misadministration greater than 20% of prescribed dose and greater than 50 Rem to the lung tissue occurred on 6/2/08.  The prescribed dose was 1.0 ml of P-32 chromic phosphate into two separate syringe applications.
 The technician prepared the first P-32 dose into syringe "A" and recorded into the written record after calibrated assay as 1.3 ml and performed the same procedure for the second dose which was recorded into the written record as 1.0 ml into syringe "B". The first dose in syringe "A" exceeded the allowable dose.  Both syringe applications were given to the patient into separate lung tube injections.