Event Notification Report for July 27, 2016
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
07/26/2016 - 07/27/2016
EVENT NUMBERS
52131
Agreement State
Event Number: 52131
Rep Org: WA OFFICE OF RADIATION PROTECTION
Licensee: VIRGINIA MASON MEDICAL CENTER
Region: 4
City: SEATTLE State: WA
County:
License #: WA-M048
Agreement: Y
Docket:
NRC Notified By: TRISTAN HAY
HQ OPS Officer: STEVE SANDIN
Licensee: VIRGINIA MASON MEDICAL CENTER
Region: 4
City: SEATTLE State: WA
County:
License #: WA-M048
Agreement: Y
Docket:
NRC Notified By: TRISTAN HAY
HQ OPS Officer: STEVE SANDIN
Notification Date: 07/28/2016
Notification Time: 20:00 [ET]
Event Date: 07/27/2016
Event Time: 00:00 [PDT]
Last Update Date: 07/28/2016
Notification Time: 20:00 [ET]
Event Date: 07/27/2016
Event Time: 00:00 [PDT]
Last Update Date: 07/28/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
GREG PICK (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)
GREG PICK (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)
AGREEMENT STATE REPORT - PATIENT RECEIVED LESS THAN THE PRESCRIBED DOSE OF I-131
The following information was provided by the State of Washington via email:
"At approximately 3:50 pm [PDT] on Thursday, July 28th 2016, the Director of Radiology of Virginia Mason Medical Center called the radioactive materials section [WA Office of Radiation Protection] to report a medical event. The event occurred on the previous day, July 27th 2016, but was not noticed until the 28th . A patient was supposed to receive 120.8 mCi of I-131 in the form of two capsules for thyroid treatment. However, the patient only received one capsule resulting in the patient only receiving 53 mCi of the 120.8 mCi. The event was discovered (8:45 am [on] July 28, 2016) when an I-131 capsule was returned to the pharmacy on the 28th and it was noticed that the patient did not get both capsules as intended."
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.
The following information was provided by the State of Washington via email:
"At approximately 3:50 pm [PDT] on Thursday, July 28th 2016, the Director of Radiology of Virginia Mason Medical Center called the radioactive materials section [WA Office of Radiation Protection] to report a medical event. The event occurred on the previous day, July 27th 2016, but was not noticed until the 28th . A patient was supposed to receive 120.8 mCi of I-131 in the form of two capsules for thyroid treatment. However, the patient only received one capsule resulting in the patient only receiving 53 mCi of the 120.8 mCi. The event was discovered (8:45 am [on] July 28, 2016) when an I-131 capsule was returned to the pharmacy on the 28th and it was noticed that the patient did not get both capsules as intended."
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.