ENS Event | |
|---|---|
07:00 Mar 11, 2020 | |
| Title | Agreement State - Patient Underdose |
| Event Description | The following report was received via e-mail from the California Department of Public Health - Radiation Health Branch [CDPH-RHB]:
On March 13, 2020, the licensee radiation safety officer (RSO) contacted CDPH-RHB to report a medical event which occurred on March 11, 2020, and was discovered on March 13, 2020. The licensee reported that a patient was prescribed 200 mCi of I-131 NaI for the treatment of thyroid cancer, but received only 60 mCi on the day of therapy (March 11, 2020). The 200 mCi dose was divided into two capsules and the patient was unintentionally only provided one of the two capsules in a medicine cup by the authorized user. The second capsule was reportedly stuck in the shipping vial which the authorized user thought he had emptied. The 140 mCi I-131 capsule was returned to the radiopharmacy in the shipping vial and pig. This error was discovered when the radiopharmacy contacted the licensee on March 13, 2020 to inform them of the capsule's presence in the returned vial. The Medical Director of Nuclear Medicine was immediately notified, who in turn, notified the RSO. The referring physician was also notified on March 13, 2020 and took responsibility for notifying the patient. A subsequent dosage was administered to complete the therapeutic treatment. This medical event was initially reported to CDPH-RHB by telephone on March 13, 2020 and by written report dated March 27, 2020. However, CDPH-RHB does not believe that the medical event was reported to the NRC at that time. A recent inspection by CDPH-RHB brought this medical event to their current attention." 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. |
| Where | |
|---|---|
| The Regents Of The University Of California, Uc Davis Sacramento, California (NRC Region 4) | |
| License number: | 1334-57 |
| Organization: | California Radiation Control Prgm |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+9781.75 h407.573 days <br />58.225 weeks <br />13.399 months <br />) | |
| Opened: | Robert Greger 20:45 Apr 22, 2021 |
| NRC Officer: | Brian P. Smith |
| Last Updated: | Apr 22, 2021 |
| 55208 - NRC Website | |
The Regents Of The University Of California, Uc Davis with Agreement State | |
WEEKMONTHYEARENS 552082020-03-11T07:00:00011 March 2020 07:00:00
[Table view]Agreement State Agreement State - Patient Underdose 2020-03-11T07:00:00 | |