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Event Notification Report for March 27, 2006

U.S. Nuclear Regulatory Commission
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Event Reports For
03/24/2006 - 03/27/2006

** EVENT NUMBERS **


42440 42441

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General Information or Other Event Number: 42440
Rep Org: NH DEPT OF HEALTH & HUMAN SERVICES
Licensee: MARY HITCHCOCK MEMORIAL HOSPITAL
Region: 1
City: LEBANON State: NH
County:
License #: 130R
Agreement: Y
Docket:
NRC Notified By: TWILA KENNA
HQ OPS Officer: DORIS LEWIS
Notification Date: 03/22/2006
Notification Time: 16:19 [ET]
Event Date: 03/03/2006
Event Time: [EST]
Last Update Date: 03/22/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
HAROLD GRAY (R1)
PATRICIA HOLAHAN (NMSS)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT INVOLVING THE WRONG RADIOPHARMACEUTICAL

The following information was received via facsimile:

"NH Radiological Health Section 'Agency' was notified on March 7, 2006, by an e-mail from the Radiation Safety Officer (RSO) at Mary Hitchcock Memorial Hospital of the wrong radiopharmaceutical injected into a patient. [The] delay was caused by conflicting information concerning whether the dose administered exceeded the reporting threshold. Four millicuries of Tl-201 Cl [Thallium Chloride] was administered [via] IV to a patient instead of the intended Tc-99 pertechnetate. Due to the error, the administration resulted in a whole body dose of 5.2 Rem. The patient and both the Authorized User and referring physician were notified of the error and the correct radiopharmaceutical was administered.

"The Licensee's RSO conducted an investigation and interviewed persons involved with the administration. A written explanation of the event was obtained. [The] cause of [the] incident was identified as inattention to labeling on part of [the] technician. Remedial instruction was given to the technician.

NH Report ID No: NH-06-001

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General Information or Other Event Number: 42441
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: CARDINAL HEALTH
Region: 4
City: COLTON State: CA
County:
License #: CA5218-36
Agreement: Y
Docket:
NRC Notified By: KEN FUREY
HQ OPS Officer: BILL GOTT
Notification Date: 03/22/2006
Notification Time: 16:10 [ET]
Event Date: 03/22/2006
Event Time: [PST]
Last Update Date: 03/22/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JEFFREY CLARK (R4)
TRISH HOLAHAN (NMSS)

Event Text

AGREEMENT STATE REPORT - RADIATION EXPOSURE

The State provided the following information via email:

"The Manager Health Physics, Cardinal Health called to report an incident which occurred today out of their Colton, CA pharmacy. A generator was being shipped via contract carrier from Colton to their Palm Springs pharmacy. The wrong shielding was used. Instead of a [Transportation Index] TI 1 which it was shipped as it was actually a TI 20. Upon arriving at the Palm Springs pharmacy it had a surface reading of 1,000 mr/hr. Estimate 4 hours with the driver. [The Manager Health Physics] was not aware if the driver had a personnel exposure device or what type of vehicle was utilized or the distance the generator was from the driver."

CA Report Number: 032206

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Friday, March 30, 2012