ENS 57073: Difference between revisions
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| title = Agreement State - Medical Underdose | | title = Agreement State - Medical Underdose | ||
| event text = The following information was provided by the South Carolina Department of Health and Environmental Control (Department) via email: | | event text = The following information was provided by the South Carolina Department of Health and Environmental Control (Department) via email: | ||
The South Carolina Department of Health and Environmental Control was notified via telephone at approximately 1301 [EDT] on 4/12/24, that a medical event had been discovered by the licensee on 4/12/24 at approximately 1130 [EDT]. The Medical University of South Carolina (MUSC) reports an underdose to a patient | The South Carolina Department of Health and Environmental Control was notified via telephone at approximately 1301 [EDT] on 4/12/24, that a medical event had been discovered by the licensee on 4/12/24 at approximately 1130 [EDT]. The Medical University of South Carolina (MUSC) reports an underdose to a patient's liver during a Y-90 microsphere procedure by 78 percent of the prescribed 120 Gray (Gy) dose. The licensee estimates that the patient received 27 Gy, which is 22 percent of the intended 120 Gy dose. The licensee reports that the total dose or activity delivered differs from the prescribed dose or activity, as documented in the written directive, by 20 percent or more. The patient was notified of this medical event verbally. | ||
The licensee reports no immediate or ongoing concerns to public health and safety. Department inspectors will be dispatched to the facility to investigate this event. This event is still under investigation by the South Carolina Department of Health and Environmental Control. | The licensee reports no immediate or ongoing concerns to public health and safety. Department inspectors will be dispatched to the facility to investigate this event. This event is still under investigation by the South Carolina Department of Health and Environmental Control. | ||
A Medical Event may indicate potential problems in a medical facility | 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. | ||
* * * UPDATE ON 04/26/2024 AT 0934 EDT FROM ADAM GAUSE TO JOSUE RAMIREZ * * * | * * * UPDATE ON 04/26/2024 AT 0934 EDT FROM ADAM GAUSE TO JOSUE RAMIREZ * * * | ||
The following update was provided by the South Carolina Department of Health and Environmental Control via email: | The following update was provided by the South Carolina Department of Health and Environmental Control via email: | ||
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* * * UPDATE ON 06/14/2024 AT 1211 EDT FROM KORINA KOCI TO ROBERT THOMPSON * * * | * * * UPDATE ON 06/14/2024 AT 1211 EDT FROM KORINA KOCI TO ROBERT THOMPSON * * * | ||
The following information was provided by the licensee via email: | The following information was provided by the licensee via email: | ||
Department Inspectors performed an on-site investigation on 05/23/24. Details of the event were consistent with the licensee | Department Inspectors performed an on-site investigation on 05/23/24. Details of the event were consistent with the licensee's notification and written report. The licensee attributes the root cause of the failure to administer the full dosage to the administration lines due to administration line blockage, specifically a faulty needle in the plunger of the administration kit. This event is considered closed. | ||
Notified R1DO (Eve), NMSS_EVENTS_NOTIFICATION via email. | Notified R1DO (Eve), NMSS_EVENTS_NOTIFICATION via email. | ||
| URL = https://www.nrc.gov/reading-rm/doc-collections/event-status/event/2024/20240617en.html#en57073 | | URL = https://www.nrc.gov/reading-rm/doc-collections/event-status/event/2024/20240617en.html#en57073 | ||
Latest revision as of 23:38, 18 June 2024
| Where | |
|---|---|
| Medical University Of South Carolina Charleston, South Carolina (NRC Region 1) | |
| License number: | 081 |
| Organization: | Sc Dept Of Health & Env Control |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+-1.62 h-0.0675 days <br />-0.00964 weeks <br />-0.00222 months <br />) | |
| Opened: | Korina Koci 13:53 Apr 12, 2024 |
| NRC Officer: | Ernest West |
| Last Updated: | Jun 14, 2024 |
| 57073 - NRC Website
| |