ENS Event | |
|---|---|
04:00 Mar 27, 2009 | |
| Title | Missed Confirmations Led to Patient Receiving a Higher Dose |
| Event Description | A patient was prescribed a 12 millicurie dose of I-131 for treatment. When the hospital requested the dose from the pharmacy, a 15 millicurie dose was mistakenly requested. The dose requested was not confirmed against the prescribed dose.
When the patient came in for treatment, the technologist preparing the dose measured a 15.5 millicurie dose but did not realize or confirm that this dose differed from the 12 millicurie prescribed dose. The 15.5 millicurie dose was administered instead of a 12 millicurie dose resulting in a dose to the patient of more than a 20% difference from the prescribed dose. The licensee will inform the patient of the higher dose. To prevent this same type of incident from happening in the future the hospital plans on changing current practice to confirm two different times that the prescribed dose and the requested dose from the pharmacy are the same. 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 | |
|---|---|
| Regional Medical Imaging - Flint Flint, Michigan (NRC Region 3) | |
| License number: | 21-26076-01 |
| Organization: | Medical Physics Consultants |
| Reporting | |
| 10 CFR 35.3045(a)(1) | |
| Time - Person (Reporting Time:+8.5 h0.354 days <br />0.0506 weeks <br />0.0116 months <br />) | |
| Opened: | Laura Luna 12:30 Mar 27, 2009 |
| NRC Officer: | Pete Snyder |
| Last Updated: | Mar 27, 2009 |
| 44941 - NRC Website | |
Regional Medical Imaging - Flint with 10 CFR 35.3045(a)(1) | |
WEEKMONTHYEARENS 449412009-03-27T04:00:00027 March 2009 04:00:00
[Table view]10 CFR 35.3045(a)(1) Missed Confirmations Led to Patient Receiving a Higher Dose 2009-03-27T04:00:00 | |