ENS Event | |
|---|---|
05:00 Aug 27, 2015 | |
| Title | Agreement State Report - Medical Overdose |
| Event Description | The following was received via email:
On August 27th 2015, a patient with 21st [Century] Oncology who was prescribed a 67.13 mCi dose of Sm-153 received an 86.9 mCi dose. The resulting over dose was more than 29.5 [percent] of the prescribed dose. The error was discovered through discrepancies in their pharmacies inventory when a new order was created for a new patient. On Feb 15, 2016, [21st Century Oncology] were preparing an order for Sm-153 for a new patient. The nurse referred to the last administered Samarium case (August 27, 2015) for information on activity, patient weight and pricing. In order to clarify the relation between dosage and patient weight, he asked the physics staff to perform a second check of the records. When the requested check was done the following error was discovered. Upon re-evaluation of the treatment procedure, the physics staff determined that the dosage of 91 mCi received from the pharmacy was not correctly calculated for the patient weight that was specified on the original order. The pharmacy was then requested to fax back the original order (Form J). The fax which they sent confirmed the correct weight of the patient (148 lbs). For this weight a correct calculation would have indicated an activity of 67.13 mCi. Instead the pharmacy had shipped the (incorrect) activity of 91 mCi. The resulting delivered dosage was 29.5 [percent] more than the prescribed dose. Thus [the staff] concluded that a medical event had occurred. The Radiation Oncologist notified the referring physician on February 16, 2016. The Radiation Oncologist also will note this communication in the patient's chart. Florida Incident Number: FL 16-029 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 | |
|---|---|
| 21St Century Oncology Plantation, Florida (NRC Region 1) | |
| License number: | 2499-1 |
| Organization: | Florida Bureau Of Radiation Control |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+4230.58 h176.274 days <br />25.182 weeks <br />5.795 months <br />) | |
| Opened: | Kellie Anderson 12:35 Feb 19, 2016 |
| NRC Officer: | Steven Vitto |
| Last Updated: | Feb 19, 2016 |
| 51745 - NRC Website | |
21St Century Oncology with Agreement State | |
WEEKMONTHYEARENS 517452015-08-27T05:00:00027 August 2015 05:00:00
[Table view]Agreement State Agreement State Report - Medical Overdose ENS 484112012-10-15T07:00:00015 October 2012 07:00:00 Agreement State Agreement State Report - Dose Different from Prescribed ENS 425562006-03-31T04:00:00031 March 2006 04:00:00 Agreement State Agreement State Report - Medical Event 2015-08-27T05:00:00 | |