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 |
| 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 | |
Mary Hitchcock Memorial Hospital with Agreement State | |
WEEKMONTHYEARENS 567822023-10-05T04:00:0005 October 2023 04:00:00
[Table view]Agreement State Agreement State - Greater than Anticipated Dose to NON-TARGET Organ ENS 524472016-11-23T05:00:00023 November 2016 05:00:00 Agreement State Agreement State Report - Medical Event Involving High Dose Rate Therapy Dose to an Unintended Location ENS 424402006-03-03T05:00:0003 March 2006 05:00:00 Agreement State Agreement State Report - Medical Event Involving the Wrong Radiopharmaceutical 2023-10-05T04:00:00 | |