AGREEMENT STATE REPORT - RADIOTHERAPY UNDERDOSE
The following report was received via fax:
"On April 13, 2012, a patient was to receive a prescribed dose of 100 mCi of iodine-131 (I-131) for thyroid cancer. Two capsules of I-131 were received from the radiopharmacy in a single vial which was assayed to assure proper dose prior to administering to the patient. The patient was given the contents of the vial for treatment and the treatment was considered complete. The Nuclear Medicine staff prepared the remaining container for return to the radiopharmacy on Monday April 16, 2012. The radiopharmacy picked up the I-131 container and returned it to their facility. Upon inspection of the returned package, the radiopharmacy discovered that one of the two capsules intended for the treatment remained lodged in the vial. The radiopharmacy informed Tristan and the RSO at 12:30 EDT on Monday April 16, 2012. The patient received 50 mCi of the intended 100 mCi dose.
"Patient and referring physician are in the process of being notified. The [PA] Department [of Radiation Protection] plans to do a reactive inspection on April 17, 2012."
PA Event ID: PA120013
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. |