ENS Event | |
|---|---|
05:00 Sep 2, 2009 | |
| Title | Agreement State Report - Medical Dose Different than Prescribed |
| Event Description | The following information was received via facsimile:
This incident was reported to the DEP [Pennsylvania Department of Environmental Protection Bureau of Radiation Protection] Eastern Regional Office by the licensee via a phone call on September 3, 2009, but wasn't considered a ME [Medical Event] by DEP at the time. On September 2, 2009 a patient was prescribed a dose of 150 millicuries (mCi) of radioactive iodine-131 (I-131) for a therapeutic treatment of thyroid cancer. The nuclear medicine technologist took the 150 mCi dose to the patient's room in a lead container and made the appropriate tube connections. The connections were checked with water prior to administration of the I-131 and no leaks were present. The dose was administered. During the flushing process, the technologist noted some leakage of liquid on the absorbent material that was placed under the tubing. The syringe, tubing, and absorbent material were immediately removed and assayed in the dose calibrator. It was determined that 57.6% of the prescribed dose had been administered to the patient. A second written directive for an additional dose prescribed by the authorized user was delivered to provide assurance that the patient received the appropriate complete amount of radioactive iodine for treatment of the thyroid cancer. During an inspection of Fox Chase on December 1, 2009, this incident was reviewed by the DEP. At this point the licensee informed DEP that they considered this a ME, had notified the patient, thus, the reason for this fax ME notification to the NRC HOO [Headquarter Operation Officer] at this point in time. Additional details will be provided in the NMED report. Pennsylvania Event Report: PA090034. 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 | |
|---|---|
| Fox Chase Cancer Center Philadelphia, Pennsylvania (NRC Region 1) | |
| License number: | PA-0293 |
| Organization: | Pa Bureau Of Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+2219.32 h92.472 days <br />13.21 weeks <br />3.04 months <br />) | |
| Opened: | David Allard 17:19 Dec 3, 2009 |
| NRC Officer: | Vince Klco |
| Last Updated: | Dec 3, 2009 |
| 45540 - NRC Website | |
Fox Chase Cancer Center with Agreement State | |
WEEKMONTHYEARENS 537372018-11-13T05:00:00013 November 2018 05:00:00
[Table view]Agreement State Agreement State Report- Irradiator Access Control System Inoperable ENS 455402009-09-02T05:00:0002 September 2009 05:00:00 Agreement State Agreement State Report - Medical Dose Different than Prescribed 2018-11-13T05:00:00 | |