ENS Event | |
|---|---|
10:00 Jun 2, 2008 | |
| Title | Potential Misadministration Greater Than 20% Of Prescribed Dose |
| Event Description | The RSO performed a quarterly audit on 9/2/08 and discovered that a misadministration greater than 20% of prescribed dose and greater than 50 Rem to the lung tissue occurred on 6/2/08. The prescribed dose was 1.0 ml of P-32 chromic phosphate into two separate syringe applications.
The technician prepared the first P-32 dose into syringe "A" and recorded into the written record after calibrated assay as 1.3 ml and performed the same procedure for the second dose which was recorded into the written record as 1.0 ml into syringe "B". The first dose in syringe "A" exceeded the allowable dose. Both syringe applications were given to the patient into separate lung tube injections. The prescribing physician and authorized user have been notified. It is not known if the patient has been notified.
Based on further review of this event by the licensee, it was determined that the total dose to the lung was less than 50 Rem. As a result, the event does not meet reportability criteria under 10CFR35.3045. The licensee has reviewed its conclusion with NRC Region 4 inspectors (Whitten and Munoz). R4DO (Jones) and FSME (Turtil) have been notified. |
| Where | |
|---|---|
| Queens Medical Center Honolulu, Hawaii (NRC Region 4) | |
| License number: | 53-16533-02 |
| Organization: | Queens Medical Center |
| Reporting | |
| 10 CFR 35.3045(a)(1) | |
| Time - Person (Reporting Time:+2236.02 h93.168 days <br />13.31 weeks <br />3.063 months <br />) | |
| Opened: | Brian Oytomari 14:01 Sep 3, 2008 |
| NRC Officer: | Joe O'Hara |
| Last Updated: | Sep 5, 2008 |
| 44461 - NRC Website | |
Queens Medical Center with 10 CFR 35.3045(a)(1) | |
WEEKMONTHYEARENS 444612008-06-02T10:00:0002 June 2008 10:00:00
[Table view]10 CFR 35.3045(a)(1) Potential Misadministration Greater than 20% of Prescribed Dose 2008-06-02T10:00:00 | |