The possible medical event occurred at a medical broad-scope permittee authorized under the master materials license issued to the Department of Veterans Affairs, NRC License 03-23853-01VA. The permittee is
VA Medical Center, Ann Arbor,
Michigan (Permit # 21-00159-01).
The possible medical event occurred on December 29, 2003. The possible medical event was discovered on January 21, 2004.
The basis for the possible medical event is under 10 CFR 35.3045(a)(2)(i) and involved administration of a wrong radiopharmaceutical drug. Specifically, the written directive for a patient therapy procedure incorrectly listed Strontium 90 when in fact Strontium 89 was administered to the patient.
Since the clinical intent was for the patient to receive Strontium 89, the possible medical event will not have any adverse impact on the patient.
The permittee has implemented corrective actions to prevent a recurrence of the circumstances that resulted in the possible medical event. The Department of Veterans Affairs will evaluate the circumstances related to the possible medical event and submit a written report to NRC, Region III, within 15 days.