ILLINOIS - HOSPITAL ADMINISTERED 10.8 MCI THYROID DOSE TO WRONG PATIENT IN BARRINGTON

GOOD SHEPHERD HOSPITAL (BARRINGTON, IL) - NOTIFICATION DATE: 06/23/2003

AGREEMENT STATE REPORT- WRONG PATIENT SELECTED

"Today, June 23, 2003, a consultant to Good Shepherd Hospital (IL-01620-01) in Barrington, IL called concerning a reportable medical event [discovery date 06/20/2003]. On June 17th the licensee was scheduled to provide a therapeutic dose of 15 milliCi [milliCuries] of I-131 to a patient by capsule. Instead, the patient received a capsule with an assayed dose of 10.8 milliCi. Apparently, two treatments were scheduled for the day and a second patient was prescribed a dose of 11 milliCi and the technician failed to administer the correct dose to the patient. The second patient did not receive any treatment that day and was rescheduled for last Friday. (A separate call to the pharmacy confirmed two doses were delivered on Tuesday, one of 15 milliCi and a second [dose] of 11 milliCi and another dose of 10 milliCi was provided on Friday.)

"At this time, the radiation oncologist does not believe there will be any appreciable effect to the patient, but will continue to follow through with the evaluation to determine if an additional dose is necessary to achieve the optimal results. The licensee has advised the referring physician verbally and in writing. They have determined it would not be appropriate to notify the patient[s] given their condition and medical situation.

"The licensee has spoken with the responsible technician about ensuring the correct dose is administered to the correct patient. The licensee is in the process of changes procedures at the site so that two individuals must independently confirm the correct patient identification and dosage information immediately prior to administration.

"The licensee was advised as the need for timely reporting or these events and that a formal report must be filed within 15 days as per 32 Ill. Adm. Code 335.1080."

+------------------------------------------------------------------------------+ |General Information or Other |Event Number: 39957 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | REP ORG: ILLINOIS DEPT OF NUCLEAR SAFETY |NOTIFICATION DATE: 06/23/2003| |LICENSEE: GOOD SHEPHERD HOSPITAL |NOTIFICATION TIME: 17:26[EDT]| | CITY: BARRINGTON REGION: 3 |EVENT DATE: 06/17/2003| | COUNTY: STATE: IL |EVENT TIME: [CDT]| |LICENSE#: IL-01620-01 AGREEMENT: Y |LAST UPDATE DATE: 06/23/2003| | DOCKET: |+----------------------------+ | |PERSON ORGANIZATION | | |PATRICK LOUDEN R3 | | |C.W. (BILL) REAMER NMSS | +------------------------------------------------+ | | NRC NOTIFIED BY: DAREN PERRERO | | | HQ OPS OFFICER: ARLON COSTA | | +------------------------------------------------+ | |EMERGENCY CLASS: NON EMERGENCY | | |10 CFR SECTION: | | |NAGR AGREEMENT STATE | | | | | +------------------------------------------------------------------------------+

Source: The above is excerpted from NRC Operations Center, Event Notification Report for June 27, 2003