ENS Event | |
|---|---|
07:00 Jun 29, 2023 | |
| Title | Medical Misadministration |
| Event Description | The following information was provided by the Arizona Department of Health Services (The Department) via email:
The Department received notification from the licensee about a medical event involving I-131. On June 29, 2023, two patients were scheduled to receive I-131 doses of 75 and 100 millicuries (mCi) each. When the certified nuclear medicine technologist (CNMT) was preparing the first dose for the patient (75 mCi), the CNMT assayed the wrong dose but with the correct paperwork. The authorized user was present for the administration and gave the patient a 100 mCi dose of I-131 when the prescribed dose was for 75 mCi. The licensee discovered the mistake prior to giving the second patient (prescribed 100 mCi) the incorrect dose of 75 mCi. The Department has requested additional information and continues to investigate the event." 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 | |
|---|---|
| Banner University Medical Center Phoenix, Arizona (NRC Region 4) | |
| License number: | 07-478 |
| Organization: | Arizona Dept Of Health Services |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+17.55 h0.731 days <br />0.104 weeks <br />0.024 months <br />) | |
| Opened: | Brian D. Goretzki 00:33 Jun 30, 2023 |
| NRC Officer: | Karen Cotton-Gross |
| Last Updated: | Jun 30, 2023 |
| 56599 - NRC Website | |
Banner University Medical Center with Agreement State | |
WEEKMONTHYEARENS 565992023-06-29T07:00:00029 June 2023 07:00:00
[Table view]Agreement State Medical Misadministration ENS 562182022-11-10T07:00:00010 November 2022 07:00:00 Agreement State Patient Underdose 2023-06-29T07:00:00 | |