Event Notification Report for August 11, 2003
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
08/10/2003 - 08/11/2003
EVENT NUMBERS
40059
Hospital
Event Number: 40059
Rep Org: REYNOLDS ARMY COMMUNITY HOSPITAL
Licensee: U.S. ARMY
Region: 4
City: Ft. Sill State: OK
County: Comanche
License #: NMC-NU-1
Agreement: Y
Docket:
NRC Notified By: NELSON UZQUIANO
HQ OPS Officer: HOWIE CROUCH
Licensee: U.S. ARMY
Region: 4
City: Ft. Sill State: OK
County: Comanche
License #: NMC-NU-1
Agreement: Y
Docket:
NRC Notified By: NELSON UZQUIANO
HQ OPS Officer: HOWIE CROUCH
Notification Date: 08/13/2003
Notification Time: 19:11 [ET]
Event Date: 08/11/2003
Event Time: 00:00 [CDT]
Last Update Date: 08/13/2003
Notification Time: 19:11 [ET]
Event Date: 08/11/2003
Event Time: 00:00 [CDT]
Last Update Date: 08/13/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
PHIL HARRELL (R4)
JOHN HICKEY (NMSS)
SONIA BURGESS (R3)
PHIL HARRELL (R4)
JOHN HICKEY (NMSS)
SONIA BURGESS (R3)
PATIENT RECEIVES THERAPEUTIC DOSE INSTEAD OF DIAGNOSTIC DOSE OF I-131
On 8/13/03, the Chief Radiologist determined that a patient undergoing a diagnostic procedure had been given a dose of I-131 that far exceeds the customary diagnostic dose for a whole body scan.
A patient at the hospital was incorrectly prescribed 5 milliCuries of I-131 and received 5.45 milliCuries of I-131 in preparation for a diagnostic scan evaluation for sub-sternal ectopic thyroid tissue. Additionally, the patient has a history of Grave's disease (a malady affecting the thyroid). According to the Chief Radiologist, the customary dose for this type of procedure is in the 1-2 milliCuries range.
The patient has been notified by the hospital and will undergo further diagnostic imaging. The patient has undergone counseling at the hospital concerning the radiation effects of the I-131. Additionally, family members of the patient will be given bioassays to determine uptake, if any. The prescribing physician will be notified. The Medical Command Radiation Safety Officer has been notified.
The hospital has placed procedural precautions in place to minimize the chances of a future occurrence of this event. Henceforth, all diagnostic uses of I-131 will be approved by the Chief Radiologist. The only allowed diagnostic uses will be for whole body scans for follow-up evaluations of the efficacy of thyroid cancer treatment or for the treatment of Grave's disease.
On 8/13/03, the Chief Radiologist determined that a patient undergoing a diagnostic procedure had been given a dose of I-131 that far exceeds the customary diagnostic dose for a whole body scan.
A patient at the hospital was incorrectly prescribed 5 milliCuries of I-131 and received 5.45 milliCuries of I-131 in preparation for a diagnostic scan evaluation for sub-sternal ectopic thyroid tissue. Additionally, the patient has a history of Grave's disease (a malady affecting the thyroid). According to the Chief Radiologist, the customary dose for this type of procedure is in the 1-2 milliCuries range.
The patient has been notified by the hospital and will undergo further diagnostic imaging. The patient has undergone counseling at the hospital concerning the radiation effects of the I-131. Additionally, family members of the patient will be given bioassays to determine uptake, if any. The prescribing physician will be notified. The Medical Command Radiation Safety Officer has been notified.
The hospital has placed procedural precautions in place to minimize the chances of a future occurrence of this event. Henceforth, all diagnostic uses of I-131 will be approved by the Chief Radiologist. The only allowed diagnostic uses will be for whole body scans for follow-up evaluations of the efficacy of thyroid cancer treatment or for the treatment of Grave's disease.