ENS Event | |
|---|---|
12:30 May 10, 2021 | |
| Title | Medical Event - Patient Underdose |
| Event Description | The following report was received via email from the VA National Health Physics Program (NHPP):
VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, which holds Permit Number 37-01230-03 under the VA master materials license, reported discovery of a medical event to NHPP at approximately 0730 EDT, May 10, 2021. An iodine-131 sodium iodide thyroid ablation therapy administration was performed on Friday, May 7, 2021. The prescribed dose was 60 milliCuries but only 31.2 milliCuries were delivered. The patient and the referring physician have been notified. NHPP will follow up with a written report in accordance with NRC requirements in 10 CFR 35.3045. NHPP notified [their] NRC Region III Project Manager, Bryan Parker.
The following retraction was received via email from the VA National Health Physics Program (NHPP): A patient at VA Pittsburgh Healthcare System was administered a therapeutic dosage of iodine-131 sodium iodide on May 7, 2021. On May 10, 2021, the facility reported to NHPP that a medical event had occurred. We reported that to NRC Operations Center on May 10, 2021, pursuant to 10 CFR 35.3045. The basis for the medical event was that the facility believed that only a little more than half of the prescribed dosage of 60 milliCuries had been administered to the patient. Since that time, measurements were made of the material not administered to the patient. These measurements indicate that about 82% of the prescribed activity was administered and therefore a medical event did not occur. Therefore, we wish to retract the report of the medical event. We have notified Bryan Parker of NRC Region III, NRC project manager for the VA's Master Material License, of our plan to withdraw the event declaration. Notified R3DO (Cameron) and NMSS Events (by email). 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 | |
|---|---|
| Va Pittsburgh Healthcare System Little Rock, Arkansas (NRC Region 3) | |
| License number: | 03-23853-01VA |
| Organization: | Va National Health Physics Program |
| Reporting | |
| 10 CFR 35.3045(a)(1) | |
| Time - Person (Reporting Time:+2.97 h0.124 days <br />0.0177 weeks <br />0.00407 months <br />) | |
| Opened: | Stan Bravenec 15:28 May 10, 2021 |
| NRC Officer: | Bethany Cecere |
| Last Updated: | May 20, 2021 |
| 55245 - NRC Website | |
Va Pittsburgh Healthcare System with 10 CFR 35.3045(a)(1) | |
WEEKMONTHYEARENS 552452021-05-10T12:30:00010 May 2021 12:30:00
[Table view]10 CFR 35.3045(a)(1) Medical Event - Patient Underdose 2021-05-10T12:30:00 | |