ENS 43201
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ENS Event | |
|---|---|
06:00 Feb 14, 2007 | |
| Title | Agreement State Report - Dispensing Error for Thallium -201 Dose |
| Event Description | The following information was provided by the state via facsimile:
Description of Event: On February 14, 2007, a customer called to report that the Thallium-201 Chloride dose they ordered was only 2.9 mCi instead of the 4.0 mCi requested. Thallium-201 Chloride is an imaging agent used for myocardial perfusion imaging or parathyroid and tumor imaging. Another TI-201 dose was sent to the customer to account for the incorrect activity. An investigation revealed that the pharmacist who dispensed the dose had selected the incorrect setting on the dose calibrator when assaying the dose at the pharmacy. The dose calibrator was set on Tc-99m instead of TI-201, resulting in an incorrect assay. Root Causes: The root cause of this event was an error by the pharmacist while assaying the dose. By not double-checking that the dose calibrator was on the correct setting, an incorrect assay was recorded. Actions Taken to Prevent a Recurrence: In an effort to prevent a recurrence of this event, the pharmacist will be sure to check that the correct isotope settings are in place on the dose calibrator for the dose being assayed. Additionally, checking the volume on the dose label will help reinforce that the pharmacist has checked which dose is being assayed and if the isotope setting is correct. LA Event Report ID No.: LA070003
|
| Where | |
|---|---|
| Cardinal Health Shreveport, Louisiana (NRC Region 4) | |
| License number: | LA-10217-L01 |
| Organization: | Louisiana Radiation Protection Div |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+342.12 h14.255 days <br />2.036 weeks <br />0.469 months <br />) | |
| Opened: | Richard Penrod 12:07 Feb 28, 2007 |
| NRC Officer: | Jeff Rotton |
| Last Updated: | Mar 13, 2007 |
| 43201 - NRC Website | |
Cardinal Health with Agreement State | |
WEEKMONTHYEARENS 573482024-09-27T09:00:00027 September 2024 09:00:00
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Radiopharmaceuticals Delivery Vehicle Accident ENS 441362008-04-09T12:00:0009 April 2008 12:00:00 Agreement State Agreement State - Mississippi - Traffic Accident Involving Truck Carrying Tc-99M ENS 441392008-03-19T04:00:00019 March 2008 04:00:00 Agreement State Agreement State - Florida - Missing Dose of Tc-99M ENS 438412007-11-19T15:13:00019 November 2007 15:13:00 Agreement State Agreement State Report - Dose to Wrong Organs ENS 437312007-09-24T05:00:00024 September 2007 05:00:00 Agreement State Agreement State Report Involving an Improper Injection ENS 434322007-05-16T05:00:00016 May 2007 05:00:00 Agreement State Louisiana Agreement State Report - Medical Event Due to Dispensing Error ENS 432012007-02-14T06:00:00014 February 2007 06:00:00 Agreement State Agreement State Report - Dispensing Error for Thallium -201 Dose ENS 429992006-11-16T06:00:00016 November 2006 06:00:00 Agreement State Agreement State - Stolen Truck Containing Radiopharmiceuticals ENS 428582006-09-22T11:00:00022 September 2006 11:00:00 Agreement State Agreement State Report - Traffic Accident Involving a Truck Carrying Radioactive Material ENS 426242006-05-22T05:00:00022 May 2006 05:00:00 Agreement State Agreement State Report - Unsecured Delivery of Radioactive Material ENS 424412006-03-22T08:00:00022 March 2006 08:00:00 Agreement State Agreement State Report - Radiation Exposure ENS 424182006-03-05T06:00:0005 March 2006 06:00:00 Agreement State Agreement State Report - Patient Received Improper Medical Dose ENS 422732006-01-18T06:00:00018 January 2006 06:00:00 Agreement State Agreement State Report of an Extremity Exposure Greater than Limit ENS 422362005-12-29T16:45:00029 December 2005 16:45:00 Agreement State Agreement State Report - Transportation Accident Involving Used Technetium 99M Syringes ENS 422232005-12-22T12:30:00022 December 2005 12:30:00 Agreement State Agreement State Report of Traffic Accident Involving Radioactive Material ENS 418402005-06-26T21:20:00026 June 2005 21:20:00 Agreement State Agreement State - Medical Sources Stolen ENS 414692005-03-08T13:40:0008 March 2005 13:40:00 Agreement State Agreement State Report - Truck Containing Radiopharmaceuticals Stolen in Massachusetts ENS 413512005-01-20T17:00:00020 January 2005 17:00:00 Agreement State Agreement State Report Involving a Pharmacy Spill of Samarium-153 ENS 413062005-01-01T10:00:0001 January 2005 10:00:00 Agreement State Agreement State Report of Truck Crash Resulting in Minor Contamination and Loss of Radiopharmaceutical Vials ENS 412712004-10-25T20:00:00025 October 2004 20:00:00 Agreement State Agreement State Medical Event ENS 409362004-08-09T13:30:0009 August 2004 13:30:00 Agreement State Spill of I-131 Resulting in Contamination ENS 418332004-05-02T04:00:0002 May 2004 04:00:00 Agreement State Agreement State Report Involving a Potential Extremity Overexposure ENS 408482004-02-27T05:00:00027 February 2004 05:00:00 Agreement State Lousiana Agreement State Report - Medical Event ENS 405532004-02-26T21:00:00026 February 2004 21:00:00 Agreement State Agreement State Reports Spill at Nuclear Pharmacy 2024-09-27T09:00:00 | |
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