ENS 48856

v t e ENS Event
04:00 Jan 29, 2013
Title	Agreement State Report - Catheter Leakage During Treatment
Event Description	The Division of Radiological Health was notified on Tuesday March 26, 2013, by a representative from Vanderbilt [University], of a misadministration. A patient was treated January 29, 2013, with Iodine 131-MIBG [metaiodobenzylguanidine]. The patient stayed in the hospital for 4 days until February 2, 2013. Foley catheter leakage occurred during this interval, but not recognized as a misadministration because there was no visible effect. The patient returned for a second treatment on March 19, 2013, at that time a rash was noted and attributed to the catheter leakage during the initial treatment in January. Inspectors from the Nashville Field Office will [request additional information and] follow-up and keep NRC informed of the status of our investigation. Tennessee Division of Radiological Health Report Number: TN-13-044 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 48856 +/-
Where
Vanderbilt University Nashville, Tennessee (NRC Region 1)
License number:	R-19021-I15
Organization:	Tennessee Div Of Rad Health
Reporting

Agreement State
Time - Person (Reporting Time:+1356.38 h56.516 days <br />8.074 weeks <br />1.858 months <br />)
Opened:	Sasi Krishnasarma 15:23 Mar 26, 2013
NRC Officer:	John Shoemaker
Last Updated:	Mar 27, 2013
48856 - NRC Website
v • d • e

v t e Emergency Notification System
Vanderbilt University with Agreement State
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