ENS 43432

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v t e ENS Event
05:00 May 16, 2007
Title	Louisiana Agreement State Report - Medical Event Due to Dispensing Error
Event Description	The State provided the following information via facsimile: Description of Event - A customer called the [Cardinal Health] pharmacy on Wednesday, May 16, 2007 to report that the late injection of Tc-99m sestamibi, a heart imaging agent, showed no heart uptake on the film. Instead there was only soft tissue uptake. The activity dispensed and injected matched the prescription. The next day the patient was brought back to the department and the image indicated that the dose injected was Tc-99m medronate, a bone imaging agent. Investigation and Root Causes - A large dose of Tc-99m sestamibi was ordered at 0600 calibrated for 1400. A biliary dose was also ordered at the same time. These were the only two doses drawn at that time. After notification by the hospital, an investigation revealed that the activity and volume remaining in the sestamibi vial plus the volume and activity dispensed matched the total volume and activity of the prepared kit (after correction for decay). The concentration for the sestamibi kit is normally 30% greater than for a bone imaging kit. Since the volume was correct, no flags were detected during dispensing. It is not Cardinal Health policy to test used syringes due to blood borne pathogen hazards. No other clients that were dispensed doses from the same vial reported errors in imaging. From this analysis, Cardinal Health can find no errors on its part to account for the imaging error. Actions Taken to Prevent a Recurrence - Cardinal Health has protocols in place to prevent dispensing errors of the type described above. Since the error cannot be attributed to Cardinal Health, corrective action is unnecessary. LA event Report ID No.: LA070015 A "Medical Event" may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.

ENS 43432 +/-
Where
Cardinal Health West Monroe, Louisiana (NRC Region 4)
License number:	LA-5119-L01
Organization:	Louisiana Radiation Protection Div
Reporting

Agreement State
Time - Person (Reporting Time:+825.62 h34.401 days <br />4.914 weeks <br />1.131 months <br />)
Opened:	Richard Penrod 14:37 Jun 19, 2007
NRC Officer:	Jeff Rotton
Last Updated:	Jun 19, 2007
43432 - NRC Website
v • d • e

v t e Emergency Notification System
Cardinal Health with Agreement State
WEEKMONTHYEAR2024-02-05T14:00:00 [Table view]
[ENS list for Cardinal Health]

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