Report a Safety Concern
Search

The U.S. Nuclear Regulatory Commission is in the process of rescinding or revising guidance and policies posted on this webpage in accordance with Executive Order 14151 Ending Radical and Wasteful Government DEI Programs and Preferencing, and Executive Order 14168 Defending Women From Gender Ideology Extremism and Restoring Biological Truth to the Federal Government. In the interim, any previously issued diversity, equity, inclusion, or gender-related guidance on this webpage should be considered rescinded that is inconsistent with these Executive Orders.

Home NRC Library Document Collections Events, Reports Associated with Event Notification Reports 2001

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.                                                                       |
+------------------------------------------------------------------------------+

Page Last Reviewed/Updated Thursday, March 25, 2021