PNO-III-97-023, on 970306,patient Administered 10 Mci of I-131 for Hyperthyroidism Instead of Prescribed Dosage of 20 Mci of I-131.Nuclear Medicine Technologist Did Not Check Written Directive Prior to Administering Dosage
| ML20138F754 | |
| Person / Time | |
|---|---|
| Site: | 03008298 |
| Issue date: | 03/12/1997 |
| From: | Gattone R, Madera J NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | |
| References | |
| PNO-III-97-023, PNO-III-97-23, NUDOCS 9705060042 | |
| Download: ML20138F754 (2) | |
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MarF0ED.9EO PRELIMINARY NOTIFICATION OFgyENR Q@ U9 tis @l2DCCURRENCE PNO-III-97-023 This preliminary notificatfd@d8rsMM notice of events of
, POSSIBLE safety or public interest significance. The information is as l initially received without verification or evaluation, and is basically all that is known by Region III staff (Lisle, Illinois) on this date.
I Facility Licensee Emergency Classification GUNDERSEN CLINIC LTD. Notification of Unusual Event Lutheran Hospital Alert !
l Lacrosse, , Wisconsin Site Area Emergency ,
i License No: 48-01277-02 General Emergency X Not Applicable .
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Subject:
RADI0 PHARMACEUTICAL THERAPY MISADMINISTRATION (UNDERDOSE) ,
l On March 11, 1997, the licensee reported that a medical misadministration occurred on March 6. 1997, when a patient was administered 10 millicuries (370 megabecquerels) of iodine-131 for ,
hyperthyroidism instead of the prescribed dosage of 20 millicuries (740 I megabecquerels) of iodine-131.
l Based on verbal communications with the Nuclear Medicine Receptionist )
who had consulted with endocrinology staff, a Nuclear Medicine I Technologist administered 10 millicuries (370 megabecquerels) of l iodine-131 to the patient on March 6, 1997. The Nuclear Medicine Technologist did not check the written directive prior to administering the dosage.
The event was identified by the licensee during a routine record review on March 10, 1997. However, the licensee did not consider it a misadministration because the referring physician was notified and he directed that no additional dosage would be given to the patient. The
, referring physician will monitor the patient's response to the
! administered dosage before determining if additional iodine-131 will be i administered.
l The licensee's Radiation Safety Officer was notified of the event on March 11. 1997, and he reported the event as a misadministration to the NRC Operations Center. The licensee has informed NRC Region III
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- PNO-III-97-023 l that the referring physician plans to inform the patient about the misadministration.
Region III will perform a special inspection in response to the event.
The State of Wisconsin and the NRC Office of Nuclear Materials Safety and Safeguards have been notified. The information in this preliminary notification has been reviewed with licensee management.
The licensee notified the NRC Operations Center of this event at 3:41 p.m. (CST) on March 11, 1997. This information is current as of 11:00 a.m. on March 11, 1997.
Contact:
ROBERT GATTONE JOHN MADERA (630)829-9823 (630)829-9834
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