ENS Event | |
|---|---|
04:00 Aug 22, 2022 | |
| Title | Unintended Dose to Fetus |
| Event Description | The following information was provided by the Massachusetts Radiation Control Program (The Agency) via email:
The licensee ( Dana Farber Cancer Institute) reported by telephone on August 23, 2022, that it discovered on August 22, 2022, that it had administered on August 22, 2022, a radiopharmaceutical (10 millicuries of F-18 FDG) as part of a PET/CT diagnostic procedure to a patient that was unknowingly pregnant resulting in an estimated dose to the embryo/fetus of 20 milli-gray (20 millisievert or 2 rem). The estimated dose is inclusive of both the F-18 PET and CT components of the procedure. The reporting requirement is 105 CMR 120.594(B), Report and Notification of a Dose to an Embryo/Fetus or Nursing Child, a by no later than next calendar day of the event telephone report. The licensee reported that pregnancy screening questions were answered through an interpreter, stating that the patient was not pregnant and that the result of the PET/CT scan showed that the patient was pregnant. The licensee reported that the referring physician and the patient have been notified. The licensee reported that at this time (August 23, 2022) there is no expectation of physical/deterministic harm to the fetus from the dose received. The licensee reported that a written report will be submitted to the Agency within 15 days of the telephone report in accordance with 105 CMR 120.594(B)(4). The Agency considers this event to be open. Massachusetts Event Number: 20-5109 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 | |
|---|---|
| Dana Farber Cancer Institute Boston, Massachusetts (NRC Region 1) | |
| License number: | 60-0037 |
| Organization: | Ma Radiation Control Program |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+55.15 h2.298 days <br />0.328 weeks <br />0.0755 months <br />) | |
| Opened: | Joshua E. Daehler 11:09 Aug 24, 2022 |
| NRC Officer: | Karen Cotton-Gross |
| Last Updated: | Aug 24, 2022 |
| 56064 - NRC Website | |
Dana Farber Cancer Institute with Agreement State | |
WEEKMONTHYEARENS 560642022-08-22T04:00:00022 August 2022 04:00:00
[Table view]Agreement State Unintended Dose to Fetus 2022-08-22T04:00:00 | |