ENS Event | |
|---|---|
17:15 Jul 15, 2011 | |
| Title | Agreement State Report - Improper Therapeutic Hyperthyroid Dose |
| Event Description | Kentucky provided the following information via e-mail:
On July 15, 2011, an 82 year old male patient was scheduled for a therapeutic dose of I-131, 15 mCi for the treatment of subclinical hyperthyroidism with [the prescribing physician]. The therapeutic dose received from the radiopharmacy was assayed prior to administration and indicated an amount of 19.9 mCi. The technologist assaying the dose contacted [the physician] concerning the difference in the amount ordered and the amount received. [The physician] chose to accept the dose and administer it to the patient based on the patient's age and symptomatic subclinical hyperthyroidism and enlarged lobe. [The physician] accepted the dose clinically but did not document this on the written directive prior to administration. The change in dose is documented in [the physician's] dictation, completed on July 15, 2011 at 1:44 p.m., acknowledges the change in the dose administered and it is documented that the technologist informed him of the difference in dose and his acceptance and why this amount was acceptable. The failure to change the written directive prior to administration was not identified until August 8, 2011 during OLBH's [Our Lady of Bellefonte Hospital] annual audit conducted by a Medical Physicist. [The] RSO and the Director of Radiology contacted the RHB [Radiation Health Branch] on August 9, 2011 for notification of the medical event. Contributing Factor: Failure to change the written directive prior to administration of the I-131. Corrective Actions by Licensee: A policy and procedure review was conducted. The Quality Management form and Written Directive used with administration of I-131 therapies was reviewed and updated to include an area that requires explanation of any dose that differs from the prescribed dose being administered and the signature of the AU [authorized user] confirming the change in dose prior to administration. 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 | |
|---|---|
| Our Lady Of Bellefonte Hospital Ashland, Kentucky (NRC Region 1) | |
| License number: | 202-144-26 |
| Organization: | Kentucky Dept Of Radiation Control |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+838.4 h34.933 days <br />4.99 weeks <br />1.148 months <br />) | |
| Opened: | Michele Greenwell 15:39 Aug 19, 2011 |
| NRC Officer: | Pete Snyder |
| Last Updated: | Aug 19, 2011 |
| 47175 - NRC Website | |
Our Lady Of Bellefonte Hospital with Agreement State | |
WEEKMONTHYEARENS 471752011-07-15T17:15:00015 July 2011 17:15:00
[Table view]Agreement State Agreement State Report - Improper Therapeutic Hyperthyroid Dose ENS 464762008-03-10T06:00:00010 March 2008 06:00:00 Agreement State Agreement State Report - Medical Event - Patient Received Less than the Prescribed Dose 2011-07-15T17:15:00 | |