ENS 42418

v t e ENS Event
06:00 Mar 5, 2006
Title	Agreement State Report - Patient Received Improper Medical Dose
Event Description	The State provided the following information via facsimile: On March 5, 2006, a technician at St. Francis North Hospital contacted the Cardinal Health pharmacy to inform them that a scan on a patient had shown lung imaging instead of the expected cardiac imaging after administering a dose labeled Myoview. An investigation revealed that the customer's Tc-99m Myoview dose for cardiac imaging had mistakenly been dispensed as a Tc-99m MAA dose which is for lung imaging. The cause of this event was a failure by the dispensing pharmacist to follow proper Cardinal Health compounding procedures. The pharmacist pulled the wrong kit from the refrigerator. The pharmacist performed a QC test on the dose, but failed to label the starting point on the QC chromatography strip, which led to a misinterpretation of the failing test as a passing test. In order to prevent a recurrence of this event, the pharmacy is going to begin requiring all employees performing QC tests to label the starting point of all QC strips. Also, the pharmacy is planning to switch brands of MAA since the Drax MAA vial and the Myoview vials are identical in appearance.

ENS 42418 +/-
Where
Cardinal Health Monroe, Louisiana (NRC Region 4)
License number:	LA-5119-L01
Organization:	Louisiana Radiation Protection Div
Reporting

Agreement State
Time - Person (Reporting Time:+224.75 h9.365 days <br />1.338 weeks <br />0.308 months <br />)
Opened:	Mike Henry 14:45 Mar 14, 2006
NRC Officer:	Joe O'Hara
Last Updated:	Mar 14, 2006
42418 - NRC Website
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v t e Emergency Notification System
Cardinal Health with Agreement State
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