ENS Event | |
|---|---|
02:00 Dec 17, 2014 | |
| Title | Prescribed Dose Changed by Unauthorized User |
| Event Description | On 16 December 2014, at 1800 [PST], a patient was prescribed to receive 8-12 mCi of I-123 MIBG [metaiodobenzylguanidine]. The dose was delivered late to the Nuclear Medicine clinic and fell below the prescribed dosage range. The Nuclear Medicine OIC [Officer-in-Charge] changed the prescribed dosage from 8-12 mCi to 7-12 mCi, and the patient was subsequently dosed with 7.81 mCi. The procedure was successful and did not result in any medical/health impact or further need to repeat the study. [The Nuclear Medicine OIC] is currently not an authorized user (AU) on USAF Radioactive Material Permit No. CA-07840-03/07 AFP; therefore, he does not have the authority to adjust the prescribed dosage range. It is worth noting that [the Nuclear Medicine OIC] meets all the requirements to be an AU, and a request to add him was included with our pending permit renewal application provided to the Radioisotope Committee Secretariat (RICS) (USAF Licensee).
Location: Travis AFB, David Grant USAF Medical Center 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 | |
|---|---|
| Air Force Medical Support Agency Travis Afb, California (NRC Region 4) | |
| License number: | 42-23539-01/A |
| Organization: | Air Force Medical Support Agency |
| Reporting | |
| 10 CFR 35.3045(a)(1) | |
| Time - Person (Reporting Time:+34.95 h1.456 days <br />0.208 weeks <br />0.0479 months <br />) | |
| Opened: | Daniel Shaw 12:57 Dec 18, 2014 |
| NRC Officer: | Dong Park |
| Last Updated: | Dec 18, 2014 |
| 50692 - NRC Website | |
Air Force Medical Support Agency with 10 CFR 35.3045(a)(1) | |
WEEKMONTHYEARENS 506922014-12-17T02:00:00017 December 2014 02:00:00
[Table view]10 CFR 35.3045(a)(1) Prescribed Dose Changed by Unauthorized User 2014-12-17T02:00:00 | |