ENS 54514: Difference between revisions
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{{ENS notification | {{ENS notification | ||
| event number = 54514 | | event number = 54514 | ||
| facility = | | facility = | ||
| Organization = Minnesota Department Of Health | | Organization = Minnesota Department Of Health | ||
| license number = 1047 | | license number = 1047 | ||
| Line 10: | Line 10: | ||
| utype = | | utype = | ||
| cfr = Agreement State | | cfr = Agreement State | ||
| emergency class = | | emergency class = Non Emergency | ||
| notification date = 02/07/2020 11:52 | | notification date = 02/07/2020 11:52 | ||
| notification by = Tyler Kruse | | notification by = Tyler Kruse | ||
| Line 19: | Line 19: | ||
| event text = The following was received from the state of Minnesota via email: | | event text = The following was received from the state of Minnesota via email: | ||
Lu-177 administration was performed on February 4, 2020. The administration team did not start the patient on amino acids prior to the administration. Upon discovery of the error, the acids were started. This resulted in an unintended dose to the kidneys. The Radiation Safety Officer (RSO) and staff were notified on February 5, 2020. They determined it was a medical event on February 7, 2020 at 0930 CST. The event was reported to the Minnesota Department of Health (MDH) at 1000 CST on February 7, 2020. The intended dose to the kidney was 490 Rem. The delivered dose to the kidney was 740 Rem (this was their 'best case scenario' calculation). This would fall under 4731.4525 Subpart 1 Item C.: 'a dose to the skin or an organ or tissue other than the treatment site that exceeds 50 Rem and exceeds 50 percent of the dose expected from the administration defined in the written directive.' | Lu-177 administration was performed on February 4, 2020. The administration team did not start the patient on amino acids prior to the administration. Upon discovery of the error, the acids were started. This resulted in an unintended dose to the kidneys. The Radiation Safety Officer (RSO) and staff were notified on February 5, 2020. They determined it was a medical event on February 7, 2020 at 0930 CST. The event was reported to the Minnesota Department of Health (MDH) at 1000 CST on February 7, 2020. The intended dose to the kidney was 490 Rem. The delivered dose to the kidney was 740 Rem (this was their 'best case scenario' calculation). This would fall under 4731.4525 Subpart 1 Item C.: 'a dose to the skin or an organ or tissue other than the treatment site that exceeds 50 Rem and exceeds 50 percent of the dose expected from the administration defined in the written directive.' | ||
This event is still under investigation with MDH. | This event is still under investigation with MDH. | ||
Minnesota Event Report ID: MN200002 | Minnesota Event Report ID: MN200002 | ||
A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. | 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. | ||
| URL = https://www.nrc.gov/reading-rm/doc-collections/event-status/event/2020/20200218en.html#en54514 | | URL = https://www.nrc.gov/reading-rm/doc-collections/event-status/event/2020/20200218en.html#en54514 | ||
}} | }} | ||
{{ENS-Nav}} | {{ENS-Nav}} | ||
Latest revision as of 12:55, 15 January 2021
| Where | |
|---|---|
| Minnesota Department Of Health Rochester, Minnesota (NRC Region 3) | |
| License number: | 1047 |
| Organization: | Minnesota Department Of Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+125.87 h5.245 days <br />0.749 weeks <br />0.172 months <br />) | |
| Opened: | Tyler Kruse 11:52 Feb 7, 2020 |
| NRC Officer: | Andrew Waugh |
| Last Updated: | Feb 7, 2020 |
| 54514 - NRC Website | |