Event Notification Report for July 02, 2014
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
07/01/2014 - 07/02/2014
EVENT NUMBERS
50251
Agreement State
Event Number: 50251
Rep Org: NEW YORK CITY BUREAU OF RAD HEALTH
Licensee: LONG ISLAND JEWISH MEDICAL CENTER
Region: 1
City: NEW YORK CITY State: NY
County:
License #: 75-2986-01
Agreement: Y
Docket:
NRC Notified By: TOBIAS LICKERMAN
HQ OPS Officer: JOHN SHOEMAKER
Licensee: LONG ISLAND JEWISH MEDICAL CENTER
Region: 1
City: NEW YORK CITY State: NY
County:
License #: 75-2986-01
Agreement: Y
Docket:
NRC Notified By: TOBIAS LICKERMAN
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 07/02/2014
Notification Time: 16:23 [ET]
Event Date: 07/02/2014
Event Time: 13:00 [EDT]
Last Update Date: 07/02/2014
Notification Time: 16:23 [ET]
Event Date: 07/02/2014
Event Time: 13:00 [EDT]
Last Update Date: 07/02/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
JAMES NOGGLE (R1DO)
FSME EVENTS RESOURCE (EMAI)
JAMES NOGGLE (R1DO)
FSME EVENTS RESOURCE (EMAI)
AGREEMENT STATE REPORT - UNDERDOSE ADMINISTRATION FOR TREATMENT OF PROSTATE CANCER
The following report was received from the New York City Office of Radiological Health (NYC ORH) via facsimile:
"Type of Incident: Underdose of Sm-153 administration IV for treatment of prostate cancer.
"Location of Incident: Long Island Jewish Medical Center. New York City Radioactive Materials License No. 75-2986-01
"Date and time of Incident: 07/02/14 at 1300 EDT.
"Date and time of Report to NYC ORH: 07/02/14 at 1530 EDT.
"Date of Investigation by ORH inspector: Inspection will be assigned no later than 24 hours from time of report to the Office of Radiological Health.
"Description of event: Patient was being injected with Samarium-153 intravenously [IV], in the arm for treatment of prostate cancer.
"In preliminary telephone report by hospital, RSO stated that administration was made into the skin, rather than IV as intended. Physician's prescription was for 100 microcuries (reporting RSO twice stated 'microcuries'). Of the prescribed 100 microcuries, it was estimated that only 39.2 microcuries was delivered. Procedure was stopped in the course of delivery.
"Reporting RSO at Medical Center stated that preliminary report would be sent by email later today. Letter with details to follow."
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.
The following report was received from the New York City Office of Radiological Health (NYC ORH) via facsimile:
"Type of Incident: Underdose of Sm-153 administration IV for treatment of prostate cancer.
"Location of Incident: Long Island Jewish Medical Center. New York City Radioactive Materials License No. 75-2986-01
"Date and time of Incident: 07/02/14 at 1300 EDT.
"Date and time of Report to NYC ORH: 07/02/14 at 1530 EDT.
"Date of Investigation by ORH inspector: Inspection will be assigned no later than 24 hours from time of report to the Office of Radiological Health.
"Description of event: Patient was being injected with Samarium-153 intravenously [IV], in the arm for treatment of prostate cancer.
"In preliminary telephone report by hospital, RSO stated that administration was made into the skin, rather than IV as intended. Physician's prescription was for 100 microcuries (reporting RSO twice stated 'microcuries'). Of the prescribed 100 microcuries, it was estimated that only 39.2 microcuries was delivered. Procedure was stopped in the course of delivery.
"Reporting RSO at Medical Center stated that preliminary report would be sent by email later today. Letter with details to follow."
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.