ENS 43265

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v t e ENS Event
05:00 May 31, 2006
Title	Medical Event - Patient Received Dose Greater than Prescribed
Event Description	The possible medical event occurred at a broad-scope permittee authorized under the master materials license issued to the Department of Veterans Affairs, NRC License 03-23853-01VA. The permittee is VA Eastern Colorado Health Care System, Denver, Colorado. The possible medical event occurred on May 31, 2006. The possible medical event was discovered on March 28, 2007. The basis for the possible medical event is under 10 CFR 35.3045(a)(1)(i) and involved administration of a dose different from the dose prescribed in the written directive. Specifically, the written directive for a patient therapy procedure listed the dose to be 15 millicuries Iodine 131 when in fact 30 millicuries was given to the patient. Since the clinical intent was for the patient to receive 30 millicuries, the possible medical event will not have any adverse impact on the patient. The permittee has implemented corrective actions to prevent a recurrence of the circumstances that resulted in the possible medical event. The Department of Veterans Affairs will evaluate the circumstances related to the possible medical event and submit a written report to NRC, Region III, within 15 days. * * UPDATE ON 3/30/2007 AT 0720 FROM FLANNERY (NRC/FSME) VIA E-MAIL TO ABRAMOVITZ * * * 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 43265 +/-
Where
Department Of Veterans Affairs Little Rock, Arkansas (NRC Region 4)
License number:	03-23583-01VA
Organization:	Department Of Veterans Affairs
Reporting

10 CFR 35.3045(a)(1)
Time - Person (Reporting Time:+7255.8 h302.325 days <br />43.189 weeks <br />9.939 months <br />)
Opened:	Gary Williams 12:48 Mar 29, 2007
NRC Officer:	Jason Kozal
Last Updated:	Mar 30, 2007
43265 - NRC Website
v • d • e

v t e Emergency Notification System
Department Of Veterans Affairs with 10 CFR 35.3045(a)(1)
WEEKMONTHYEAR2015-02-24T06:00:00 [Table view]
[ENS list for Department Of Veterans Affairs]

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