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Medical Event



The attached description of a medical event, taken from the February 2,

2004, NRC Daily Events Report, describes a misadministration, in which a

patient who had been prescribed 5 uCi of I-131 was actually given 500

uCi.  This seems particularly egregious since the administration was

given on the basis of a verbal order.  Those administering the

radionuclide should have been aware of the provisions of 10 CFR

35.40(a), or equivalent MA regulations, that require a written directive

for administering > 30 uCi of I-131.  I hope that the corrective actions

include an upgrading of the hospital's Quality Assurance program, and

that the lessons learned are shared with the industry, to prevent

recurrences.



I have one other comment:



NCRP Report No. 65, "Management of Persons Accidently Contaminated With

Radionuclides," states (page 86) that for accidental exposures to

radioiodine, "Daily administration of 300 mg KI should be continued for

7 to 14 days.  The continuation of the blocking agent is needed to

prevent recycling of the radioiodine..."  The event report states that

the patient was given a blocking agent, but does not say anything about

continuing administration.  Has this been done?



Hospital Event Number: 40490

Rep Org: US DEPT OF VETERANS AFFAIRS

Licensee: VA BOSTON HEALTHCARE SYSTEM

Region: 1

City: BOSTON State: MA

County:

License #: 03-23853-01VA

Agreement: Y

Docket:

NRC Notified By: GARY WILLIAMS

HQ OPS Officer: STEVE SANDIN  Notification Date: 01/30/2004

Notification Time: 13:26 [ET]

Event Date: 01/30/2004

Event Time: 11:51 [EST]

Last Update Date: 01/30/2004

Emergency Class: NON EMERGENCY

10 CFR Section:

35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE

 Person (Organization):

PATRICK LOUDEN (R3)

GLENN MEYER (R1)

TRISH HOLAHAN (NMSS)





Event Text



MEDICAL EVENT DUE TO ADMINISTERED DOSE EXCEEDING PRESCRIBED DOSAGE TO

THE THYROID



"The medical event occurred at a medical 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

Boston Healthcare System, Boston, Massachusetts.



"The medical event occurred on January 29, 2004, and was discovered the

same day.



"The basis for the medical event is under 10 CFR 35.3045(a)(1)(ii) in

that an administered dosage differed from the prescribed dosage by more

than 20% and resulted in a dose of more than 50 rem to an organ.



"Specifically, the verbal order from the authorized user was for 5

microcuries Iodine 131 and the patient was given 500 microcuries Iodine

131. After the event was discovered, the patient was given a thyroid

blocking solution. Based on the patient's resultant thyroid uptake, the

permittee computed a dose to the thyroid of approximately 83 rem.



"The authorized user does not anticipate any adverse medical effects to

the patient.



"The permittee has implemented initial corrective actions to prevent a

recurrence of the circumstances that resulted in the medical event.



"The Department of Veterans Affairs will evaluate the circumstances

related to the medical event and submit a written report to NRC, Region

III, within 15 days."





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