ENS Event | |
|---|---|
07:00 Jan 18, 2013 | |
| Title | Unplanned Iodine-131 Dose to an Embryo |
| Event Description | A female patient with a previously removed thyroid, was treated for remnant thyroid cancer on January 18, 2013. She received an I-131 therapy dose of 58 mCi. On February 21, 2013, the radiation oncologist was informed by the primary physician that the patient had tested positive on a pregnancy test. The patient received an ultrasound on February 25, 2013 and the conception date was determined to be January 14, 2013. Based on the patient therapy activity received, an embryo dose of 15 Rem was calculated. Physician review of the ultrasound was determined to be normal for the embryo. The radiation oncologist is in contact with the primary physician and the patient.
Based on a telephone notification made by Douglas Heidorn, Radiation Safety Officer (RSO) at 1950 EDT on 3/25/2013, it was agreed that a written justification for a retraction would be submitted. The following is a synopsis of what Dr. Heidorn submitted. The Radiation Oncologist (Prescribing Physician) and RSO originally thought that the fetal dose was 14.6 rem, but upon further investigation, it was determined that the fetal dose was only 52 mrem. The discrepancy in the dose estimate was due to confusion about the exact conception date (fetal age). The Prescribing Physician has been corresponding with a Professor of Pediatrics and Radiology (Expert Physician) regarding this issue. The Expert Physician believes that conception occurred between 1/27/2013 and 1/29/2013. Another obstetrician at SJRMC and the Referring Physician concur with the Expert Physician's date range for conception. The 52 mrem fetal dose rate is based on this conception date. On 3/11/2013, a second ultrasound was performed that confirms the above information. Both ultrasound reports indicate the fetus is growing and has normal characteristics. As a corrective action, the Radiation Department will immediately adopt a policy that requires any female aged 12-60 shall receive a pregnancy test 48 hours5.555556e-4 days <br />0.0133 hours <br />7.936508e-5 weeks <br />1.8264e-5 months <br /> prior to an I-131 administration. Notified R4DO (Pick) and FSME Event Resources (via E-mail). |
| Where | |
|---|---|
| St Joseph Regional Medical Center Lewiston, Idaho (NRC Region 4) | |
| License number: | 11-27371-01 |
| Organization: | St Joseph Regional Medical Center |
| Reporting | |
| 10 CFR 35.3047(a) > 50 Msv | |
| Time - Person (Reporting Time:+941.7 h39.238 days <br />5.605 weeks <br />1.29 months <br />) | |
| Opened: | Doug Heidorn 12:42 Feb 26, 2013 |
| NRC Officer: | Vince Klco |
| Last Updated: | Mar 26, 2013 |
| 48784 - NRC Website | |
St Joseph Regional Medical Center with 10 CFR 35.3047(a) | |
WEEKMONTHYEARENS 487842013-01-18T07:00:00018 January 2013 07:00:00
[Table view]10 CFR 35.3047(a) Unplanned Iodine-131 Dose to an Embryo 2013-01-18T07:00:00 | |