Event Notification Report for May 27, 2003
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
05/26/2003 - 05/27/2003
EVENT NUMBERS
39892
General Information or Other
Event Number: 39892
Rep Org: ARIZONA RADIATION REGULATORY AGENCY
Licensee: Phoenix Baptist Hospital & Medical Center
Region: 4
City: PHOENIX State: AZ
County:
License #: 070-146
Agreement: Y
Docket:
NRC Notified By: WILLIAM A. WRIGHT
HQ OPS Officer: HOWIE CROUCH
Licensee: Phoenix Baptist Hospital & Medical Center
Region: 4
City: PHOENIX State: AZ
County:
License #: 070-146
Agreement: Y
Docket:
NRC Notified By: WILLIAM A. WRIGHT
HQ OPS Officer: HOWIE CROUCH
Notification Date: 05/29/2003
Notification Time: 17:19 [ET]
Event Date: 05/27/2003
Event Time: 00:00 [MST]
Last Update Date: 05/30/2003
Notification Time: 17:19 [ET]
Event Date: 05/27/2003
Event Time: 00:00 [MST]
Last Update Date: 05/30/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
KRISS KENNEDY (R4)
MELVYN LEACH (NMSS)
KRISS KENNEDY (R4)
MELVYN LEACH (NMSS)
AGREEMENT STATE REPORT - ARIZONA
The following information was obtained from the Arizona Radiation Regulatory Agency via facsimile:
"On May 27, 2003, a patient was administered 27 mCi of Iodine-131 (Iodide) instead of the prescribed dose of 5 mCi. Initial investigation indicates that Medi-Physics Inc. had mistakenly sent a 27 mCi dose designated for AMI to Phoenix Baptist Hospital and the 5 mCi dose for Phoenix Baptist Hospital to AMI. It appears that the 27 mCi dose had been accurately assayed by the Technician, had been noted to differ from the requested 5 mCi, but had been administered to the patient anyway. It should also be noted that the patient had a thyroid ablation procedure conducted previously. Medi-Physics Inc. and Phoenix Baptist Hospital are investigating the situation and a report from each will be forthcoming.
"The Agency and licensees will continue to investigate this occurrence and report further."
The following information was obtained from the Arizona Radiation Regulatory Agency via facsimile:
"On May 27, 2003, a patient was administered 27 mCi of Iodine-131 (Iodide) instead of the prescribed dose of 5 mCi. Initial investigation indicates that Medi-Physics Inc. had mistakenly sent a 27 mCi dose designated for AMI to Phoenix Baptist Hospital and the 5 mCi dose for Phoenix Baptist Hospital to AMI. It appears that the 27 mCi dose had been accurately assayed by the Technician, had been noted to differ from the requested 5 mCi, but had been administered to the patient anyway. It should also be noted that the patient had a thyroid ablation procedure conducted previously. Medi-Physics Inc. and Phoenix Baptist Hospital are investigating the situation and a report from each will be forthcoming.
"The Agency and licensees will continue to investigate this occurrence and report further."