On Wednesday, September 17, 2008, [a Certified Nuclear Medical Technologist] at Universal Health Services of Rancho Springs, Inc., contacted
RHB about a diagnostic misadministration, which had occurred on September 11, 2008. The patient was prescribed a 7 milliCurie dose of Tc-99m Hebrofenin for a Hepatobiliary study (HIDA). At approximately 2:10 P.M. on September 11, 2008, the patient was given a dose of 22 milliCuries of Tc-99m Sestamibi, used for cardiac studies. The dose given was 50% greater than the intended dose. No additional Tc-99m was given since the image required was obtained with the dose that was actually given. The technician had grabbed the wrong syringe from the dose cart. The reason given for the misadministration was a heavy workload. The corrective actions to be taken to prevent a recurrence were to implement new procedures for radiopharmaceutical labeling and handling and to reinstruct personnel. Since the dose administered to the patient was 50% greater than the prescribed dose, the reportability of this event is
24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />. This event will be investigated by
RHB South.
California Report #5010-091708
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.
- * * RETRACTION AT 1044 ON 9/18/2008 FROM DELIA AQUINO TO MARK ABRAMOVITZ * * *
The following report was received via e-mail:
The state of California is retracting this event. "After additional review, we determined that it was not actually a reportable event.
The dose the individual received did not meet the threshold necessary to be reportable under 10CFR35.3045 - Medical Event.
Notified the R4DO (Pick) and
FSME (Einberg).