PNO-III-97-090, on 971110,patient Scheduled to Receive 296 Mbq I-131 for Treatment of Hyperthyroid Condition Received 170.2 Mbq.Patient Returned & Was Administered Additional Dose: Difference between revisions
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d 4 | d 4 November 13, 1997 PRELIMINARY NOTIFICATION OF EVENT OR UNUSUAL OCCURRENCE PNO-III-97-090 i | ||
November 13, 1997 PRELIMINARY NOTIFICATION OF EVENT OR UNUSUAL OCCURRENCE PNO-III-97-090 | This preliminary notification constitutes EARLY notice of events of POSSIBLE safety or public interest significance. The information is as initially received without verification or evaluation, and is basically all that is known by Region III staff (Lisle, Illinois) on this date. | ||
Facility | Facility Licensee Emergency Classification MCLAREN REGIONAL MEDICAL CENTER Notification of Unusual Event Mclaren Regional Medical Center Alert Flint, Michigan Site Area Emergency License No: 21-04171-04 General Emergency X Not Applicable | ||
X Not Applicable | |||
==Subject:== | ==Subject:== | ||
REPORT OF RADIOPHARMACEUTICAL MISADMINISTRATION On November 11, 1997, the licensee's consultant notified the NRC of a misadministration of iodine-131 (I-131) that the licensee identified as having occurred on November 10, 1997. A patient was scheduled to receive 296 MBq (8 millicuries) of I-131 for treatment of a hyperthyroid condition. A vial containing two capsules of I-131 was given to the l | REPORT OF RADIOPHARMACEUTICAL MISADMINISTRATION On November 11, 1997, the licensee's consultant notified the NRC of a misadministration of iodine-131 (I-131) that the licensee identified as having occurred on November 10, 1997. A patient was scheduled to receive 296 MBq (8 millicuries) of I-131 for treatment of a hyperthyroid condition. A vial containing two capsules of I-131 was given to the l | ||
patient to be administered orally After the patient left the medical center, it was discovered that one of the capsules was still remaining in the vial with a measured activity of 129.5 MBq (3.5 millicuries). | |||
According to the licensee, the nuclear medicine technologist responsible for the administration stated that she had assayed the capsule twice and the indicated activity was 292.3 MBq (7.9 millicuries). | According to the licensee, the nuclear medicine technologist responsible for the administration stated that she had assayed the capsule twice and the indicated activity was 292.3 MBq (7.9 millicuries). | ||
U on further review, shipping papers indicated the total activity of the p | |||
I-131 to be 299.7 MBq (8.1 millicuries). The licensee contacted the j | |||
vendor to verify the shipment. The vendor indicated that two capsules had been shipped with activities of 170.2 MBq (4.6 millicuries) and 129.5 MBq (3.5 millicuries), therefore the patient received an administration of I-131 of only 170.2 MBq (4.6 millicuries). | |||
The licensee contacted the patient, who returned to the medical center on November 12, 1997, and was administered the second capsule. The misadministration had no adverse affect on the patient. | The licensee contacted the patient, who returned to the medical center on November 12, 1997, and was administered the second capsule. The misadministration had no adverse affect on the patient. | ||
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The information in this preliminary notification has been reviewed with the licensee, t | The information in this preliminary notification has been reviewed with the licensee, t | ||
Region III will conduct a special inspection during the week of November 17, 1997, to review the circumstances of the misadministration. | Region III will conduct a special inspection during the week of November 17, 1997, to review the circumstances of the misadministration. | ||
P% | P% | ||
V >* | |||
9901200003 971113 % | 9901200003 971113 % | ||
PDR | PDR 18sE 1 | ||
M PNO-III-97-090 PDR d p | |||
R | |||
.. ~... _. -- | |||
l | l 1 | ||
PAGE 2 | PAGE 2 | ||
* PN397090 The hospital reported this event to the NRC Operations Center at 3:11 p.m. (EST) on November 11, 1997. This information is current as of 1 p.m. | * PN397090 The hospital reported this event to the NRC Operations Center at 3:11 p.m. | ||
(EST) on November 11, 1997. This information is current as of 1 p.m. | |||
on November 12, 1997. | on November 12, 1997. | ||
==Contact:== | ==Contact:== | ||
JAMNES CAMERON | JAMNES CAMERON BOB HAYS (630)D29-9833 (630)829-9819 l | ||
[ | [ | ||
i | i | ||
Latest revision as of 00:40, 7 December 2024
| ML20206R551 | |
| Person / Time | |
|---|---|
| Site: | 03002048 |
| Issue date: | 11/13/1997 |
| From: | Jamnes Cameron, Hays B NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | |
| References | |
| PNO-III-97-090, PNO-III-97-90, NUDOCS 9901200003 | |
| Download: ML20206R551 (2) | |
. - - _
d 4 November 13, 1997 PRELIMINARY NOTIFICATION OF EVENT OR UNUSUAL OCCURRENCE PNO-III-97-090 i
This preliminary notification constitutes EARLY notice of events of POSSIBLE safety or public interest significance. The information is as initially received without verification or evaluation, and is basically all that is known by Region III staff (Lisle, Illinois) on this date.
Facility Licensee Emergency Classification MCLAREN REGIONAL MEDICAL CENTER Notification of Unusual Event Mclaren Regional Medical Center Alert Flint, Michigan Site Area Emergency License No: 21-04171-04 General Emergency X Not Applicable
Subject:
REPORT OF RADIOPHARMACEUTICAL MISADMINISTRATION On November 11, 1997, the licensee's consultant notified the NRC of a misadministration of iodine-131 (I-131) that the licensee identified as having occurred on November 10, 1997. A patient was scheduled to receive 296 MBq (8 millicuries) of I-131 for treatment of a hyperthyroid condition. A vial containing two capsules of I-131 was given to the l
patient to be administered orally After the patient left the medical center, it was discovered that one of the capsules was still remaining in the vial with a measured activity of 129.5 MBq (3.5 millicuries).
According to the licensee, the nuclear medicine technologist responsible for the administration stated that she had assayed the capsule twice and the indicated activity was 292.3 MBq (7.9 millicuries).
U on further review, shipping papers indicated the total activity of the p
I-131 to be 299.7 MBq (8.1 millicuries). The licensee contacted the j
vendor to verify the shipment. The vendor indicated that two capsules had been shipped with activities of 170.2 MBq (4.6 millicuries) and 129.5 MBq (3.5 millicuries), therefore the patient received an administration of I-131 of only 170.2 MBq (4.6 millicuries).
The licensee contacted the patient, who returned to the medical center on November 12, 1997, and was administered the second capsule. The misadministration had no adverse affect on the patient.
[
NMSS and the State of Michigan were notified of the misadministration.
The information in this preliminary notification has been reviewed with the licensee, t
Region III will conduct a special inspection during the week of November 17, 1997, to review the circumstances of the misadministration.
P%
V >*
9901200003 971113 %
PDR 18sE 1
M PNO-III-97-090 PDR d p
R
.. ~... _. --
l 1
PAGE 2
- PN397090 The hospital reported this event to the NRC Operations Center at 3:11 p.m.
(EST) on November 11, 1997. This information is current as of 1 p.m.
on November 12, 1997.
Contact:
JAMNES CAMERON BOB HAYS (630)D29-9833 (630)829-9819 l
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