ENS 46719

v t e ENS Event
04:00 Apr 1, 2011
Title	Agreement State Report - I-131 Administered Dose Less than Prescribed Dose
Event Description	The following was received from the State of Florida via email: A patient was scheduled to receive a 150 mCi dose of I-131 for thyroid cancer therapy treatment on 3/31/11. The dose was two 75 mCi capsules. Only one pill was taken. The other pill was discovered sticking on the bottom of the vial on 4/1/11 (capsules are sticky and the label around the vial prevented direct observation of the capsule from the side). Patient was under dosed by 50%. The tech failed to ensure that both pills were taken. The physician has been notified and he will notify the patient. The patient will be redosed to bring the dose up to prescription. The dosing procedure will be changed to require the tech to verify that the vial is empty. Licensee will submit a written report. Any further action on this incident is referred to Radioactive Materials. This office will take no further action on this incident. Florida Incident Number: FL 11-028 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 46719 +/-
Where
University Of Miami Miami, Florida (NRC Region 1)
License number:	33136
Organization:	Florida Bureau Of Radiation Control
Reporting

Agreement State
Time - Person (Reporting Time:+12.4 h0.517 days <br />0.0738 weeks <br />0.017 months <br />)
Opened:	Charles Adams 16:24 Apr 1, 2011
NRC Officer:	Dong Park
Last Updated:	Apr 1, 2011
46719 - NRC Website
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