ENS Event | |
|---|---|
07:00 Dec 15, 2018 | |
| Title | Agreement State Report - Medical Misadministration |
| Event Description | The following was received from the State of Colorado via email:
[Colorado Department of Public Health and Environment] CDPHE became aware of a misadministration on the evening of December 18th, 2018; the event was discovered by the licensee on the morning of December 18th, 2018. The event occurred over three consecutive days, December 15th, 16th, and 17th, 2018. Description of the events: The licensee reported that strontium break through occurred on a Braco (Rb-82) generator resulting in levels of Sr-82/Sr-85 exceeding manufacture specified limits. The licensee failed to identify the strontium breakthrough and the doses were subsequently used in patient procedures, eight (8) patients were affected. The licensee has no more information at this time and has been instructed to notify the department as soon as patient dose information becomes available. CDPHE is awaiting a full report by the licensee. 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 | |
|---|---|
| Swedish Medical Center Englewood, Colorado (NRC Region 4) | |
| License number: | CO 251-02 |
| Organization: | Colorado Dept Of Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+100.17 h4.174 days <br />0.596 weeks <br />0.137 months <br />) | |
| Opened: | Derek Bailey 11:10 Dec 19, 2018 |
| NRC Officer: | Joanna Bridge |
| Last Updated: | Dec 19, 2018 |
| 53794 - NRC Website | |
Swedish Medical Center with Agreement State | |
WEEKMONTHYEARENS 569302024-01-19T20:00:00019 January 2024 20:00:00
[Table view]Agreement State Y-90 Microsphere Misadministration ENS 540222019-04-23T07:00:00023 April 2019 07:00:00 Agreement State Washington Agreement State Report - Lost and Found Radioactive Material ENS 538042018-12-19T08:00:00019 December 2018 08:00:00 Agreement State En Revision Imported Date 1/18/2019 ENS 537942018-12-15T07:00:00015 December 2018 07:00:00 Agreement State Agreement State Report - Medical Misadministration ENS 533772018-01-23T18:30:00023 January 2018 18:30:00 Agreement State Agreement State Report - Patient Received Dose Less than Prescribed Dose ENS 435352007-07-17T17:00:00017 July 2007 17:00:00 Agreement State Agreement State Report - Six Lost Palladium - 103 Seeds ENS 415012005-03-17T20:00:00017 March 2005 20:00:00 Agreement State Argeement State Medical Event ENS 410782004-09-24T07:00:00024 September 2004 07:00:00 Agreement State Agreement State Report ENS 403372003-11-17T08:00:00017 November 2003 08:00:00 Agreement State Patient Received an Overdose During a Brachytherapy Procedure 2024-01-19T20:00:00 | |