PNO-I-97-029, on 970509,apparent Misadministration Involving under-dosing Patient w/I-131 Occurred.Two Technologists Involved in Measurement of Dose.Patient Properly Identified & Dose Administered.State of Ny Notified

PNO-I-97-029:on 970509,apparent Misadministration Involving under-dosing Patient w/I-131 Occurred.Two Technologists Involved in Measurement of Dose.Patient Properly Identified & Dose Administered.State of Ny Notified

ML20141B898
Person / Time
Site:	03002618
Issue date:	05/15/1997
From:	Everhart D, Shanbaky M NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
To:
References
PNO-I-97-029, PNO-I-97-29, NUDOCS 9705160054
Download: ML20141B898 (2)

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DCS No.:

03002618970509 Date:

May 15, 1997 I

PREl.IMINARY NOTIFICATION OF EVENT OR UNUSUAL OCCURRENCE PN1-97-029 This preliminary notification constitutes EARLY notice of. events of POSSIBLE safety or public interest significance. The information is as initially received without

'a verification or evaluation, and is basically all that is known by the Region I staff on

.this date.

Facility:

Licensee Emergency Classification:

Department of Veterans Affairs Medical Center Notification of Unusual Event 3495 Bailey Avenue Alert Buffalo, New York 14215 Site Area Emergency l

General Emergency i

XX Not Applicable Docket No.:

030-02618 License No..

31-00786-02 Event.No.:

. Event Location Code:

SUBJECT:

APPARENT MISADMINISTRATION' INVOLVING UNDER-DOSING A PATIENT WITH:1-131 On May 14. 1997, the licensee reported a misadministration to the Headquarters Duty Officer. The licensee stated that on Friday, May 9,1997, they administered 54 microcuries (uC1) of Iodine-131 (I-131), approximately one percent of the 3rescribed dose of 5 millicuries (mci), to a patient for a whole body scan.

Two tec1nologists l

were involved in the measurement of the dose.

The first technologist picked up the wrong capsule, assayed it and recorded 54 uCi, without comparing the measured dose to the 3rescribed dose. The second technologist noted that the dose measured in the dose L

cali3rator was 54 uCi but also failed to verify that this was the correct prescribed dose.

When the patient returned to the de)artment as scheduled on Tuesday, May 13, 1997, the L

licensee noted a lack of activity w1en attempting to perform the whole body scan.

The correct capsule was assayed and verified, the authorized user prepared a second written directive authorizing the administration of what was then 3.6 mci of I-131 for a whole body scan.

The patient was properly identified and the dose was administered.

Region I will perform an inspection of the nuclear medicine program and implementation of the licensee's quality management program.

The State of New York has been notified.

The Public Affairs Office is prepared to respond to media inquiries.

This information is current as of 11:30 a.m., May 15,1997.

Contact:

-David B. Everhart Mohamed M. Shanbaky (610) 337-6936 (610) 337-5209 i

9705160054 970515

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PDR I&E pg PNO-I-97-029 PDR J

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DISTRIBUTION:

l OWFN TWFN LST Mail: DCD Cha,irmansJackson AE00 PDR DOT:Trans only**

Contn. Rogers IRM Comm. Dicus ACRS Comm. Diaz Comm. McGaffigan Jr.

OCAA NRC Ops Ctr 0IP OCA NMSS OGC OIG INPO**

OPA RES NSAC**

EDO DE OSP NRR** (Phone Verif: Violet Bowden 415-1168 or 415-1166)

SECY Regional Offices RI Resident Office Licensee:

(Reactor Licensees)

• • General list for sending PNs by FAX Region I Form 83 (Rev. August 1996) 1 i

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