Event Notification Report for August 22, 2017
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
08/21/2017 - 08/22/2017
EVENT NUMBERS
52920
Agreement State
Event Number: 52920
Rep Org: MARYLAND DEPT OF THE ENVIRONMENT
Licensee: CHESAPEAKE UROLOGY
Region: 1
City: OWINGS MILLS State: MD
County:
License #: MD-05-208-01
Agreement: Y
Docket:
NRC Notified By: ALLEN GOLDERY
HQ OPS Officer: RICHARD SMITH
Licensee: CHESAPEAKE UROLOGY
Region: 1
City: OWINGS MILLS State: MD
County:
License #: MD-05-208-01
Agreement: Y
Docket:
NRC Notified By: ALLEN GOLDERY
HQ OPS Officer: RICHARD SMITH
Notification Date: 08/23/2017
Notification Time: 10:45 [ET]
Event Date: 08/22/2017
Event Time: 09:30 [EDT]
Last Update Date: 08/23/2017
Notification Time: 10:45 [ET]
Event Date: 08/22/2017
Event Time: 09:30 [EDT]
Last Update Date: 08/23/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
SILAS KENNEDY (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)
SILAS KENNEDY (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)
AGREEMENT STATE REPORT- MEDICAL EVENT MISADMINISTRATION
This following report was phoned in, followed by an email:
"On August 22, 2017, Chesapeake Urology, notified the Maryland Radiological Health Program (RHP) that a male patient was injected with 176.1 microCuries of Ra-223 (Xofigo) instead of 108.4 microCuries of Ra-223 (Xofigo); 62.5 percent greater than the prescribed dose. The wrong unit dose was handed to the authorized user for patient administration. The event occurred at approximately 0930 [EDT] hours on 08/22/2017 at the licensee's address of 21 Crossroads Drive, Suite 200, Owings Mills, MD 21117. Maryland RHP was notified by telephone at 1505 hours. Two patients were scheduled for treatment on August 22, 2017. Both doses were assayed in the morning. Each dose had the proper patient name on the lead pig and on each respective syringe. The incorrect dose was selected and injected without cross referencing the identity of the patient. The event was discovered at approximately 1130 hours when the second Xofigo dose was to be administered. The patient and the referring physician have been informed of the misadministration. A written notification from the licensee is expected in about a week. This is a preliminary notification."
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.
This following report was phoned in, followed by an email:
"On August 22, 2017, Chesapeake Urology, notified the Maryland Radiological Health Program (RHP) that a male patient was injected with 176.1 microCuries of Ra-223 (Xofigo) instead of 108.4 microCuries of Ra-223 (Xofigo); 62.5 percent greater than the prescribed dose. The wrong unit dose was handed to the authorized user for patient administration. The event occurred at approximately 0930 [EDT] hours on 08/22/2017 at the licensee's address of 21 Crossroads Drive, Suite 200, Owings Mills, MD 21117. Maryland RHP was notified by telephone at 1505 hours. Two patients were scheduled for treatment on August 22, 2017. Both doses were assayed in the morning. Each dose had the proper patient name on the lead pig and on each respective syringe. The incorrect dose was selected and injected without cross referencing the identity of the patient. The event was discovered at approximately 1130 hours when the second Xofigo dose was to be administered. The patient and the referring physician have been informed of the misadministration. A written notification from the licensee is expected in about a week. This is a preliminary notification."
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.