ENS 41763: Difference between revisions
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| event date = 06/10/2005 EDT | | event date = 06/10/2005 EDT | ||
| last update date = 06/22/2005 | | last update date = 06/22/2005 | ||
| title = Fractional Dose Delivered Differed | | title = Fractional Dose Delivered Differed from the Prescribed Dose | ||
| event text = A hyperthyroid therapy patient received one of the intended two Nal-131 capsules sent by the radio pharmacy for the therapy. The patient received 10.2 mCi in one capsule instead of the intended 20.6 mCi in two capsules. Both capsules were received in one plastic vial inside of a lead shield. The entire vial was assayed and the assay of 20.6 mCi was within 10% of the prescribed dose of 20.0 mCi. The technologist failed to notice that there were two capsules in the vial because a desiccant inside the vial blocked the view of the second capsule and prevented the second capsule from leaving the vial. Normally, hyperthyroid therapy doses are received in one capsule. Therefore, the technologist was not expecting a second capsule. | | event text = A hyperthyroid therapy patient received one of the intended two Nal-131 capsules sent by the radio pharmacy for the therapy. The patient received 10.2 mCi in one capsule instead of the intended 20.6 mCi in two capsules. Both capsules were received in one plastic vial inside of a lead shield. The entire vial was assayed and the assay of 20.6 mCi was within 10% of the prescribed dose of 20.0 mCi. The technologist failed to notice that there were two capsules in the vial because a desiccant inside the vial blocked the view of the second capsule and prevented the second capsule from leaving the vial. Normally, hyperthyroid therapy doses are received in one capsule. Therefore, the technologist was not expecting a second capsule. | ||
The radio pharmacy discovered the second capsule when the package was returned to the pharmacy the next day, June 10, 2005. They called the Nuclear Medicine department at 8:30 am on June 10, 2005. The prescribing physician was called and he requested that the patient receive the second capsule. The patient returned to the Nuclear Medicine department at 10:00 am on June 10, 2005 and received the second capsule, which assayed at 9.74 mCi at that time. The total dose the patient received was 19.94 mCi. | The radio pharmacy discovered the second capsule when the package was returned to the pharmacy the next day, June 10, 2005. They called the Nuclear Medicine department at 8:30 am on June 10, 2005. The prescribing physician was called and he requested that the patient receive the second capsule. The patient returned to the Nuclear Medicine department at 10:00 am on June 10, 2005 and received the second capsule, which assayed at 9.74 mCi at that time. The total dose the patient received was 19.94 mCi. | ||
Latest revision as of 22:20, 1 March 2018
| Where | |
|---|---|
| Edward W. Sparrow Regional Center Lansing, Michigan (NRC Region 3) | |
| License number: | 21-01430-01 |
| Organization: | Edward W. Sparrow Regional Center |
| Reporting | |
| 10 CFR 35.3045(a)(1) | |
| Time - Person (Reporting Time:+10.12 h0.422 days <br />0.0602 weeks <br />0.0139 months <br />) | |
| Opened: | Tracy Maudrie 14:07 Jun 10, 2005 |
| NRC Officer: | John Knoke |
| Last Updated: | Jun 22, 2005 |
| 41763 - NRC Website | |