ENS 42440

v t e ENS Event
05:00 Mar 3, 2006
Title	Agreement State Report - Medical Event Involving the Wrong Radiopharmaceutical
Event Description	The following information was received via facsimile: NH Radiological Health Section 'Agency' was notified on March 7, 2006, by an e-mail from the Radiation Safety Officer (RSO) at Mary Hitchcock Memorial Hospital of the wrong radiopharmaceutical injected into a patient. [The] delay was caused by conflicting information concerning whether the dose administered exceeded the reporting threshold. Four millicuries of Tl-201 Cl [Thallium Chloride] was administered [via] IV to a patient instead of the intended Tc-99 pertechnetate. Due to the error, the administration resulted in a whole body dose of 5.2 Rem. The patient and both the Authorized User and referring physician were notified of the error and the correct radiopharmaceutical was administered. The Licensee's RSO conducted an investigation and interviewed persons involved with the administration. A written explanation of the event was obtained. [The] cause of [the] incident was identified as inattention to labeling on part of [the] technician. Remedial instruction was given to the technician. NH Report ID No: NH-06-001

ENS 42440 +/-
Where
Mary Hitchcock Memorial Hospital Lebanon, New Hampshire (NRC Region 1)
License number:	130R
Organization:	Nh Dept Of Health & Human Services
Reporting

Agreement State
Time - Person (Reporting Time:+467.32 h19.472 days <br />2.782 weeks <br />0.64 months <br />)
Opened:	Twila Kenna 16:19 Mar 22, 2006
NRC Officer:	Doris Lewis
Last Updated:	Mar 22, 2006
42440 - NRC Website
v • d • e

v t e Emergency Notification System
Mary Hitchcock Memorial Hospital with Agreement State
WEEKMONTHYEAR2023-10-05T04:00:00 [Table view]
[ENS list for Mary Hitchcock Memorial Hospital]

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