ENS Event | |
|---|---|
15:00 Mar 21, 2005 | |
| Title | Medical Event - Total Dosage Delivered Is Less than the Prescribed Dosage |
| Event Description | During a quarterly review of written directives by hospital personnel, it was noted that a patient was administered a dosage of 12.51 millicuries of the isotope NaI-131 for hyperthyroidism instead of the prescribed dosage of 21 millicuries. Radiopharmaceutical unit dose dispensing records as well as internal scheduling paperwork confirm that the 12 millicuries dosage was in fact ordered and subsequently administered to the correct patient. The root cause of this event has been determined by the licensee to be lack of strict attention to detail and they have evaluated their policy and procedures to prevent reoccurrence. The attending physician has reviewed the patient's records and felt that there would be no adverse affect due to this misadministration. He will notify the patient regarding this incident. |
| Where | |
|---|---|
| Harper University Hospital Detroit, Michigan (NRC Region 3) | |
| License number: | 21-04127-02 |
| Organization: | Harper University Hospital |
| Reporting | |
| 10 CFR 35.3045(a)(1) | |
| Time - Person (Reporting Time:+21.47 h0.895 days <br />0.128 weeks <br />0.0294 months <br />) | |
| Opened: | Thomas M. Kumpuris 12:28 Mar 22, 2005 |
| NRC Officer: | Arlon Costa |
| Last Updated: | Mar 22, 2005 |
| 41515 - NRC Website | |
Harper University Hospital with 10 CFR 35.3045(a)(1) | |
WEEKMONTHYEARENS 415152005-03-21T15:00:00021 March 2005 15:00:00
[Table view]10 CFR 35.3045(a)(1) Medical Event - Total Dosage Delivered Is Less than the Prescribed Dosage 2005-03-21T15:00:00 | |