The medical event occurred at a medical broad-scope permittee authorized under the master materials license issued to the Department of Veterans Affairs, NRC License 03-23853-01VA. The permittee is
VA Boston Healthcare System, Boston,
Massachusetts.
The medical event occurred on January 29, 2004, and was discovered the same day.
The basis for the medical event is under 10 CFR 35.3045(a)(1)(ii) in that an administered dosage differed from the prescribed dosage by more than 20% and resulted in a dose of more than 50 rem to an organ.
Specifically, the verbal order from the authorized user was for 5 microcuries Iodine 131 and the patient was given 500 microcuries Iodine 131. After the event was discovered, the patient was given a thyroid blocking solution. Based on the patient's resultant thyroid uptake, the permittee computed a dose to the thyroid of approximately 83 rem.
The authorized user does not anticipate any adverse medical effects to the patient.
The permittee has implemented initial corrective actions to prevent a recurrence of the circumstances that resulted in the medical event.
The Department of Veterans Affairs will evaluate the circumstances related to the medical event and submit a written report to NRC, Region III, within 15 days.