ENS 43260

v t e ENS Event
14:00 Mar 28, 2007
Title	Agreement State Report - Incorrect Dose to Patient During I-131 Bexxar Therapy
Event Description	Mis-administration while performing l-131 therapy. Procedure is called a [Bexxar] Therapy. 74 mCi was prescribed, but the patient received only 5 to 10 mCi. T connector to catheter was not properly fitted tight enough causing connector to come loose from tubing. Some 1-131 spilled on floor. Incident happened on 28-March-2007 at 10:00 am this office notified at 11:10 am. This incident is referred to Radioactive Materials for investigation. The patient and the prescribing physician are aware of the dosing error. The licensee plans to conduct another procedure 3/30/07. The state will follow up with the licensee on this incident. This incident is being tracked as Florida incident number FL07-054. * * UPDATE FROM FLANNERY (NRC/FSME) VIA E-MAIL TO HUFFMAN AT 1530 EDT ON 3/28/07 * * * This event has been reviewed and determined to be a reportable medical event. 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.

ENS 43260 +/-
Where
University Of Miami Miami, Florida (NRC Region 1)
License number:	1319-1
Organization:	Florida Bureau Of Radiation Control
Reporting

Agreement State
Time - Person (Reporting Time:+-2.27 h-0.0946 days <br />-0.0135 weeks <br />-0.00311 months <br />)
Opened:	Steve Furnace 11:44 Mar 28, 2007
NRC Officer:	Pete Snyder
Last Updated:	Mar 28, 2007
43260 - NRC Website
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v t e Emergency Notification System
University Of Miami with Agreement State
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