ENS 44371

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v t e ENS Event
16:00 Jul 18, 2008
Title	Medical Error - Wrong Chemical Used in Patient Treatment
Event Description	On the date described [07/18/08] an outpatient reported to the Nuclear Medicine Department for a Nuclear Medicine whole body bone scan. The technician drew up and injected the patient with 24.3 mCi mTc99 Sestamibi, I.V. instead of the proper cold kit which would have been Medronate. The error was not discovered until the patient returned 3 hours3.472222e-5 days <br />8.333333e-4 hours <br />4.960317e-6 weeks <br />1.1415e-6 months <br /> later for scanning and it was observed that the isotope was not properly tagged. Upon investigation, the reason for the poor tag was discovered. The patient was informed as well as the Department Manager, and the on-duty staff Radiologist. It was agreed by all that the patient would return on 07/21/08 to perform the study properly. According to the Radiation Absorbed Dose Table, the patient received the following: Gallbladder Wall - 1.6 Rads, Small Intestine - 2.4 Rads, Upper Large Intestine Wall - 4.32 Rads, Lower Large Intestine Wall - 3.12 Rads, Stomach Wall - 0.48 Rads, Heart Wall - 0.40 Rads, Kidneys - 1.6 Rads, Liver - 0.48 Rads, Lungs - 0.24 Rads, Bone Surfaces - 0.56 Rads, Thyroid - 0.56, Testes - 0.24 Rads, Red Marrow - 0.40 Rads, Urinary Bladder Wall - 1.6 Rads, Total Body - 0.40 Rads. It is believed that there was no ill effect on the patient. The technician has been re-instructed on the extreme importance of checking all the labels previous to preparing, drawing up and delivering any radioisotopes. The licensee is still in the process of confirming that the ordering physician has been notified of this incident.

ENS 44371 +/-
Where
Memorial Hospital - Sheridan, Wy Sheridan, Wyoming (NRC Region 4)
License number:	49-10982-02
Organization:	Memorial Hospital - Sheridan, Wy
Reporting

10 CFR 35.3045(a)(2)
Time - Person (Reporting Time:+238.43 h9.935 days <br />1.419 weeks <br />0.327 months <br />)
Opened:	Thomas Nance 14:26 Jul 28, 2008
NRC Officer:	Jeff Rotton
Last Updated:	Jul 28, 2008
44371 - NRC Website
v • d • e

v t e Emergency Notification System
Memorial Hospital - Sheridan, Wy with 10 CFR 35.3045(a)(2)
WEEKMONTHYEAR2008-07-18T16:00:00 [Table view]
[ENS list for Memorial Hospital - Sheridan, Wy]

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