Event Notification Report for October 27, 2021

EN Revision Imported Date: 10/27/2021

EN Revision Text: AGREEMENT STATE REPORT - MEDICAL EVENT - UNDERDOSE OF I-131

The following report was received via email:

"Rhode Island Department of Health was notified on May 2, 2019 by a representative from Rhode Island Hospital of a medical event that occurred during an attempted dosing of 25 mCi of I-131. On April 17, 2019, a patient was administered a capsule of I-131, but was unable to swallow and the capsule began to break down in the patient's mouth. As this was not the prescribed use of the radiopharmaceutical, the staff of Rhode Island Hospital transferred the capsule to a cup as the capsule was breaking down. The cup was then brought to the lead-lined safe in the hospital's nuclear medicine hot lab. During the transfer some of the I-131 that had begun to leak from the capsule spilled onto the floor and contaminated it with I-131.

"The floor of the injection room that had been contaminated with I-131 underwent decontamination. Before decontamination, the maximum counts/min (cpm) per 100 cm squared was equal to approximately 151,000 cpm. After decontamination the maximum amount in any location was 11,000 cpm. Similarly, before the protective covering was laid over the contaminated parts of the floor, the maximum dose rate as read by Ludlum Model 9DP was 70 mR/hour on contact. Rhode Island Hospital's Radiation Safety Officer (RSO) attempted to clean up the spill and then laid protective material over the floor and measured that the dose rate upon contact with a Ludlum Model 9DP ion chamber did not exceed 70 microR per hour. No other persons or surfaces were deemed to be contaminated after surface wipe tests and a thyroid scan bioassay. The following day, April 18, 2019, 25 mCi of I-131 was attempted to be administered orally in liquid form which the patient failed to swallow as well. This did not result in a spill. The State is not performing any additional action at this time.

"The referring physician, patient, and patient's legal guardians were notified that the dose of I-131 was not received to the patient. No overexposure occurred. This event was discovered due to be reported during the October 2021 IMPEP review of the Rhode Island Radiation Control Agency."

Rhode Island Event Number: RI-21-0002

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.