ENS Event | |
|---|---|
14:30 Jan 25, 2012 | |
| Title | Misadministration of Thallium During Cardio Stress Test |
| Event Description | A patient received 100% more than the prescribed dose of thallium. The patient was to receive 3.5 milliCuries of thallium followed by 30 milliCuries of Cardiolite, a Tc-99M radiopharmaceutical. Instead, the patient received 3.5 milliCuries of thallium then received an additional 3.6 milliCuries of Thallium. The technician stated that he got confused where the patient was in the treatment process.
The patient and physician have been informed. The licensee is awaiting dosimetry results to determine the organ dosage but does not believe there will be any recurring medical effects from this event.
The licensee is retracting this event report after a review and evaluation of the doses administered. The licensee has determined that this event is not reportable based on the unintended dose being less than 5 Rem effective dose equivalent and therefore not reportable under 10 CFR 35.3045. The licensee has discussed this conclusion with NRC Region 1 (Lanzisera). R1DO (Dental) and FSME (McIntosh) have been notified. |
| Where | |
|---|---|
| Bayhealth Medical Center Milford, Delaware (NRC Region 1) | |
| License number: | 07-148-50-01 |
| Organization: | Bayhealth Medical Center |
| Reporting | |
| 10 CFR 35.3045(a)(1) | |
| Time - Person (Reporting Time:+24.87 h1.036 days <br />0.148 weeks <br />0.0341 months <br />) | |
| Opened: | Cathy Mundorf 15:22 Jan 26, 2012 |
| NRC Officer: | Joe O'Hara |
| Last Updated: | Jan 27, 2012 |
| 47623 - NRC Website | |
Bayhealth Medical Center with 10 CFR 35.3045(a)(1) | |
WEEKMONTHYEARENS 508042013-07-24T05:00:00024 July 2013 05:00:00
[Table view]10 CFR 35.3045(a)(1) Medical Misadministration During Iodine 125 Seed Implantation ENS 476232012-01-25T14:30:00025 January 2012 14:30:00 10 CFR 35.3045(a)(1) Misadministration of Thallium During Cardio Stress Test ENS 426342006-06-12T19:00:00012 June 2006 19:00:00 10 CFR 35.3045(a)(1) Medical Event - Higher Dose than Planned Administered During Brachytherapy Treatment 2013-07-24T05:00:00 | |