ENS Event | |
|---|---|
16:00 Apr 10, 2023 | |
| Title | Medical Event - Dose Received Greater than Prescribed |
| Event Description | The following information is a synopsis of information provided by the licensee:
This event occurred at Community Health Network, North Hospital on 4/10/2023 and the error was discovered at approximately 12:00 p.m. [EDT]. This procedure involved a split dose, so the patient received two separate doses in two separate locations in the liver. Hospital personnel use a spreadsheet to help with calculations while drawing the dose and to determine the administered activity after the procedure. Hospital personnel had two spreadsheets due to the split dose. When the radiation safety officer (RSO) was completing the worksheets after the procedure, she noticed that the Grays (Gy) delivered on one of the doses was much higher than anticipated. When the RSO reviewed the worksheet, she realized that she had a typo in the prescribed activity in the worksheet and did not catch it prior to administration. Typically, the physician will fill out the written directive with giga-becquerel (GBq) and the RSO would enter millicuries (mCi) in parentheses, since the dose calibrator reads in mCi. Although the worksheet converts dose, this helps as a double check when completing the written directive. In this case, the RSO had not entered mCi, only GBq and did not catch that the second dose was much higher than the prescribed activity. If the RSO had entered the mCi on the written directive (WD) as per usual, she would have caught that this dose was higher than prescribed. Initial corrective action will be to enter both GBq and mCi on the WD and give both versions of activity when doing the patient identification at the beginning of the procedure with the physician. The physician was notified immediately and she was notifying the patient. At this time there is not expected to be any detrimental effects to the patient. The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: The prescribed first dose was 43.2 mCi of Y-90 SIR-Spheres, 63.2 mCi was delivered. The prescribed second dose was 18.9 mCi and 20.8 mCi was delivered. 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 | |
|---|---|
| Community Health Network, North Hospital Indianapolis, Indiana (NRC Region 3) | |
| License number: | 13-06009-01 |
| Organization: | Community Health Network, North Hospital |
| Reporting | |
| 10 CFR 35.3045(a)(1) | |
| Time - Person (Reporting Time:+16.65 h0.694 days <br />0.0991 weeks <br />0.0228 months <br />) | |
| Opened: | Erin Bell 08:39 Apr 11, 2023 |
| NRC Officer: | Donald Norwood |
| Last Updated: | Apr 11, 2023 |
| 56463 - NRC Website | |
Community Health Network, North Hospital with 10 CFR 35.3045(a)(1) | |
WEEKMONTHYEARENS 564632023-04-10T16:00:00010 April 2023 16:00:00
[Table view]10 CFR 35.3045(a)(1) Medical Event - Dose Received Greater than Prescribed 2023-04-10T16:00:00 | |