ENS 51069
ENS Event | |
|---|---|
06:00 Feb 24, 2015 | |
| Title | Incorrect Dose Recorded on Prescription Directive |
| Event Description | This is a notification, pursuant to 10 CFR 35.3045(a)(1), of a medical event that occurred at the VA Salt Lake City Health Care System, Salt Lake City, Utah.
On February 24, 2015, a dosage of 30.8 millicuries of I-131 sodium iodide (capsule form) was administered to a patient for a thyroid ablation. The prescribed dosage on the written directive was incorrectly annotated as 3 millicuries. The basis for identifying this as a medical event is the administered dosage differed from the prescribed dosage, as annotated on the written directive, by more than 20 percent. The medical event was discovered today (May 13, 2015) during an inspection, conducted by the National Health Physics Program (NHPP). Interview of the Radiation Safety Officer revealed the standard dosage for a thyroid ablation is 30 millicuries of I-131 sodium iodide (capsule form). Interview of the authorized user (a physician) revealed the intended prescription was for 32 millicuries of I-131 sodium iodide (capsule form). No biological harm to the patient is expected since the thyroid ablation was successfully performed. The patient and attending physician were not informed of the incorrect annotation on the written directive since the thyroid ablation was successfully performed, as clinically intended, with a dosage of I-131 sodium iodide (capsule form) within an acceptable range of the authorized user's intent. The inspection is ongoing with causal factors and corrective actions being developed. Additional information will be provided in a 15-day written report, to be submitted to NRC Region III. National Health Physics Program notified NRC Region III (Patricia Pelke, Chief, Materials Licensing Branch Chief) of the medical event by telephone. The Department of Veterans Affairs holds NRC License No. 03-23853-01VA, a master materials license. Permits are issued under the license to Veterans Health Administration facilities. The VHA permit number for the facility involved in this medical event is 43-03299-01. National Health Physics Program makes required notifications to NRC. " 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 | |
|---|---|
| Department Of Veterans Affairs Salt Lake City, Utah (NRC Region 4) | |
| License number: | 03-23853-01VA |
| Organization: | Department Of Veterans Affairs |
| Reporting | |
| 10 CFR 35.3045(a)(1) | |
| Time - Person (Reporting Time:+1883.62 h78.484 days <br />11.212 weeks <br />2.58 months <br />) | |
| Opened: | Craig Adams 16:37 May 13, 2015 |
| NRC Officer: | Daniel Mills |
| Last Updated: | May 13, 2015 |
| 51069 - NRC Website | |
Department Of Veterans Affairs with 10 CFR 35.3045(a)(1) | |
WEEKMONTHYEARENS 510692015-02-24T06:00:00024 February 2015 06:00:00
[Table view]10 CFR 35.3045(a)(1) Incorrect Dose Recorded on Prescription Directive ENS 508332014-12-29T06:00:00029 December 2014 06:00:00 10 CFR 35.3045(a)(1) Medical Event - Underdose ENS 445222008-09-24T05:00:00024 September 2008 05:00:00 10 CFR 35.3045(a)(1) Medical Dose Less than 80% of Prescribed Dose ENS 432652006-05-31T05:00:00031 May 2006 05:00:00 10 CFR 35.3045(a)(1) Medical Event - Patient Received Dose Greater than Prescribed ENS 414432005-02-24T05:00:00024 February 2005 05:00:00 10 CFR 35.3045(a)(1) Medical Event 2015-02-24T06:00:00 | |