ENS 53794

v t e ENS Event
07:00 Dec 15, 2018
Title	Agreement State Report - Medical Misadministration
Event Description	The following was received from the State of Colorado via email: [Colorado Department of Public Health and Environment] CDPHE became aware of a misadministration on the evening of December 18th, 2018; the event was discovered by the licensee on the morning of December 18th, 2018. The event occurred over three consecutive days, December 15th, 16th, and 17th, 2018. Description of the events: The licensee reported that strontium break through occurred on a Braco (Rb-82) generator resulting in levels of Sr-82/Sr-85 exceeding manufacture specified limits. The licensee failed to identify the strontium breakthrough and the doses were subsequently used in patient procedures, eight (8) patients were affected. The licensee has no more information at this time and has been instructed to notify the department as soon as patient dose information becomes available. CDPHE is awaiting a full report by the licensee. Colorado Event Report ID No.: CO180032 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 53794 +/-
Where
Swedish Medical Center Englewood, Colorado (NRC Region 4)
License number:	CO 251-02
Organization:	Colorado Dept Of Health
Reporting

Agreement State
Time - Person (Reporting Time:+100.17 h4.174 days <br />0.596 weeks <br />0.137 months <br />)
Opened:	Derek Bailey 11:10 Dec 19, 2018
NRC Officer:	Joanna Bridge
Last Updated:	Dec 19, 2018
53794 - NRC Website
v • d • e

v t e Emergency Notification System
Swedish Medical Center with Agreement State
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