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Event Notification Report for July 5, 2001
U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
07/03/2001 - 07/05/2001
** EVENT NUMBERS **
38114
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|General Information or Other |Event Number: 38114 |
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| REP ORG: COLORADO DEPT OF HEALTH |NOTIFICATION DATE: 07/03/2001|
|LICENSEE: KAISER PERMANENTE |NOTIFICATION TIME: 11:30[EDT]|
| CITY: DENVER REGION: 4 |EVENT DATE: 06/29/2001|
| COUNTY: STATE: CO |EVENT TIME: [MDT]|
|LICENSE#: AGREEMENT: Y |LAST UPDATE DATE: 07/03/2001|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |LINDA HOWELL R4 |
| |DONALD COOL NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: TIM BONZER | |
| HQ OPS OFFICER: BOB STRANSKY | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
| | |
| | |
| | |
| | |
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EVENT TEXT
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| MEDICAL MISADMINISTRATIONS DUE TO INCORRECTLY CALCULATED RADIONUCLIDE |
| ACTIVITIES |
| |
| The Syncor pharmacy in Denver, CO miscalculated the activity in three doses |
| of I-131 due to the use of incorrect settings on the dose calibrator. Of the |
| three doses, two were delivered to a Kaiser Permanente facility and |
| administered. The two doses were as follows: |
| |
| Dose 1 was ordered to be 5 mCi to be used for a whole body scan. Syncor |
| believed that 5.28 mCi had been dispensed; however, the actual activity was |
| 7.97 mCi. |
| |
| Dose 2 was ordered to be 15 mCi to be used for a hyperthyroid treatment. |
| Syncor believed that 15.8 mCi had been dispensed; however, the actual |
| activity was 24 mCi. |
| |
| The state is currently following this issue with the Kaiser Permanente |
| staff. |
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Page Last Reviewed/Updated Thursday, March 25, 2021
Page Last Reviewed/Updated Thursday, March 25, 2021