Event Notification Report for March 26, 2001
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
03/25/2001 - 03/26/2001
EVENT NUMBERS
37865
Hospital
Event Number: 37865
Rep Org: PARKVIEW HOSPITAL
Licensee: PARKVIEW HOSPITAL
Region: 3
City: FORT WAYNE State: IN
County:
License #: 13-01284-02
Agreement: N
Docket:
NRC Notified By: JOHN AGNEW (RSO)
HQ OPS Officer: STEVE SANDIN
Licensee: PARKVIEW HOSPITAL
Region: 3
City: FORT WAYNE State: IN
County:
License #: 13-01284-02
Agreement: N
Docket:
NRC Notified By: JOHN AGNEW (RSO)
HQ OPS Officer: STEVE SANDIN
Notification Date: 03/27/2001
Notification Time: 13:45 [ET]
Event Date: 03/26/2001
Event Time: 11:45 [CST]
Last Update Date: 03/27/2001
Notification Time: 13:45 [ET]
Event Date: 03/26/2001
Event Time: 11:45 [CST]
Last Update Date: 03/27/2001
Emergency Class: NON EMERGENCY
10 CFR Section:
35.33 - MED MISADMINISTRATION
10 CFR Section:
35.33 - MED MISADMINISTRATION
Person (Organization):
BRUCE BURGESS (R3)
JOSIE PICCCONE
BRUCE BURGESS (R3)
JOSIE PICCCONE
MEDICAL MISADMINISTRATION INVOLVING A HIGHER THAN PRESCRIBED THERAPEUTIC DOSE OF I-131 DELIVERED
An elderly 65 year old female patient was prescribed a therapeutic 125 millicurie dose of I-131. The administering technician inadvertently delivered 160 millicuries of I-131. The error is attributed to the past practice of physicians ordering 150 millicuries doses (+/- 10%) which is what the technician ordered from the nuclear pharmacy without explicitly verifying the prescribing physician's order. The patient and referring physician were informed of the misadministration by the prescribing physician. Administrative measures including separate verification of the prescribed dosage have been implemented by the licensee to prevent recurrence. The prescribing physician concluded that there was no change in the clinical outcome and that the increased dosage did not pose a high risk for the patient. The licensee will submit a written followup report.
An elderly 65 year old female patient was prescribed a therapeutic 125 millicurie dose of I-131. The administering technician inadvertently delivered 160 millicuries of I-131. The error is attributed to the past practice of physicians ordering 150 millicuries doses (+/- 10%) which is what the technician ordered from the nuclear pharmacy without explicitly verifying the prescribing physician's order. The patient and referring physician were informed of the misadministration by the prescribing physician. Administrative measures including separate verification of the prescribed dosage have been implemented by the licensee to prevent recurrence. The prescribing physician concluded that there was no change in the clinical outcome and that the increased dosage did not pose a high risk for the patient. The licensee will submit a written followup report.