ENS 41438

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v t e ENS Event
15:35 Jan 7, 2005
Title	Agreement State Medical Event
Event Description	The following report was received from the Massachusetts Department of Public Health and Radiation Control via facsimile: Endocrinologist ordered thyroid uptake study on a patient - dose to be 17 uCi of I-131. The Central Booking Department scheduled the patient to arrive in the Nuclear Medicine Department for an I-131 'total body scan.' On 1/4/05, CNMT 1 received the appointment roster form for 1/7/05, posted it on exam scheduling bulletin board, and placed the order for a total body scan - which is generally 3.7 mCi of I-131 - without looking at the diagnosis. Total body scan ordered on roster was reviewed by Nuclear Medicine Physician and checked off for that day's activity. On the day of the exam, CNMT 2 retrieved the paper work and administered the 3.7 mCi, I-131 whole body scan. Patient sent home and came back 2 days later for thyroid scan. The imaging CNMT 3 noted that the thyroid scan did not look as expected, thus, reviewed all the paperwork and discovered that the wrong procedure (and dose) was administered. The Nuclear Medicine Physician and the RSO were then immediately notified by the CNMT 3, who in turn, notified the prescribing Endocrinologist. The Nuclear Medicine Physician then notified the patient (on 1/7/05) and the Department Administration. A summary report will be sent to the patient which will include notification that a formal report has been submitted to the Massachusetts Radiation Control Program. The patient ultimately received 3.6 mCi of I-131, had a thyroid uptake of 70% which resulted in a thyroid dose of 13,111 rads and a TEDE of 2.6 rads. This dose will be taken into consideration when the patient is treated next for hyperthyroidism.

ENS 41438 +/-
Where
Baystate Health Systems Springfield, Massachusetts (NRC Region 1)
License number:	60-0095
Organization:	Ma Radiation Control Program
Reporting

Agreement State
Time - Person (Reporting Time:+1149.1 h47.879 days <br />6.84 weeks <br />1.574 months <br />)
Opened:	Mike Whalen (Via Fax) 12:41 Feb 24, 2005
NRC Officer:	Bill Huffman
Last Updated:	Feb 24, 2005
41438 - NRC Website
v • d • e

v t e Emergency Notification System
Baystate Health Systems with Agreement State
WEEKMONTHYEAR2005-01-07T15:35:00 [Table view]
[ENS list for Baystate Health Systems]

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