ENS 41078

v t e ENS Event
07:00 Sep 24, 2004
Title	Agreement State Report
Event Description	Per Swedish Medical Center policy, post thyroid treatment patients are prescribed 74 mBq (2mCi (milliCuries)) for the treatment follow-up scan, and 185 mBq (5 mCi) for subsequent treatment if necessary. On 24 September 2004 a patient was prescribed 74 mBq (2 mCi) of NaI (Iodine-131) for a post treatment scan. Instead, 191 mBq (5.16 mCi) of NaI (Iodine-131) were administered. The prescribing physician realized that a misadministration had occurred on 27 September 2004 when the patient underwent the scan. A viable follow-up scan was able to be performed even though the misadministration had occurred. There are multiple procedural checks in place to assure medical technicians administer the prescribed dose. Human error appears to have lead to checks not being performed prior to this event. The Radiation Safety Officer for Swedish Medical Center notified the State of Washington, of the misadministration, on 27 September 2004. The treating physician notified the patient on Monday, 27 September 2004, when the physician discovered the patient had been administered 191 mBq (5.16 mCi) of NaI (Iodine-131) instead of the prescribed 74 mBq (2 mCi) of NaI (Iodine-131). Event Report Number WA-04--57

ENS 41078 +/-
Where
Swedish Medical Center Seattle, Washington (NRC Region 4)
License number:	WN-M008-1
Organization:	Wa Division Of Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+104.13 h4.339 days <br />0.62 weeks <br />0.143 months <br />)
Opened:	Arden Scroggs 15:08 Sep 28, 2004
NRC Officer:	Bill Gott
Last Updated:	Sep 28, 2004
41078 - NRC Website
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v t e Emergency Notification System
Swedish Medical Center with Agreement State
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