ENS Event | |
|---|---|
04:00 Jan 16, 2015 | |
| Title | Agreement State Report - Medical Underdose |
| Event Description | The following report was received via e-mail:
Memorial Sloan-Kettering Cancer Center reported that a pediatric male patient only received 64.38 MBq (1.74 mCi) of I-124 labeled monoclonal 8H9 on 1/16/2015, instead of the prescribed 120.25 MBq (3.25 mCi). The patient had been diagnosed with pontine glioma. The incident occurred because the infusion process along the gauze at the site of the catheter connector leaked. The leak was not obvious on visual inspection. The cause was determined to be a procedure problem. Corrective actions included generating a new procedure and improvements to radioactive material labeling and handling. NMED: 150094 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 | |
|---|---|
| Memorial Sloan Kettering Cancer Center New York City, New York (NRC Region 1) | |
| License number: | NY-75-2968-01 |
| Organization: | New York City Bureau Of Rad Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+12227.53 h509.48 days <br />72.783 weeks <br />16.749 months <br />) | |
| Opened: | Jose Lorenzo 14:32 Jun 8, 2016 |
| NRC Officer: | Mark Abramovitz |
| Last Updated: | Jun 8, 2016 |
| 51992 - NRC Website | |
Memorial Sloan Kettering Cancer Center with Agreement State | |
WEEKMONTHYEARENS 519922015-01-16T04:00:00016 January 2015 04:00:00
[Table view]Agreement State Agreement State Report - Medical Underdose 2015-01-16T04:00:00 | |