ENS Event | |
|---|---|
07:00 Apr 29, 2016 | |
| Title | Agreement State Report - Medical Misadministration |
| Event Description | The following was received from Arizona via email:
On April 29th, the licensee [Tucson Medical Center] discovered that a patient had received 37 percent more than the prescribed dose of Xofigo (Radium-223). The licensee had received two doses of Ra-223 for two patients the day prior. The technologist usually asks a patient their weight in order to re-calculate the dose, but forgot and accidently grabbed another Xofigo patient's dose on April 28th. The technologist realized the mistake when she went to inject the second patient on the 29th and the name on the patient's dose did not match the current patient's name. The prescribed dose was 86.7 microcuries and the actual administered dose was 119.3 microcuries. The investigation into this event is ongoing. The U.S. NRC and Arizona Governor's office are being notified of this event." Arizona Incident # 16-008 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 | |
|---|---|
| Tucson Medical Center Tucson, Arizona (NRC Region 4) | |
| License number: | Az 10-010 |
| Organization: | Arizona Radiation Regulatory Agency |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+31.52 h1.313 days <br />0.188 weeks <br />0.0432 months <br />) | |
| Opened: | Brian Goretzki 14:31 Apr 30, 2016 |
| NRC Officer: | Daniel Mills |
| Last Updated: | Apr 30, 2016 |
| 51894 - NRC Website | |
Tucson Medical Center with Agreement State | |
WEEKMONTHYEARENS 518942016-04-29T07:00:00029 April 2016 07:00:00
[Table view]Agreement State Agreement State Report - Medical Misadministration 2016-04-29T07:00:00 | |