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 +------------------------------------------------------------------------------+ |General Information or Other |Event Number: 38114 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | 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 | | | | | | | | | | | | | | +------------------------------------------------------------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | 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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