ENS Event | |
|---|---|
07:00 Jun 8, 2010 | |
| Title | Agreement State Report - Wrong Dose |
| Event Description | The following information was received via e-mail:
On June 8, 2010 at approximately 9:45 am, a patient scheduled for a 30 mCi TC-99m Myoview cardiac scan was mistakenly administered a 27.1 mCi Tc-99m Medronate bone dose. The mistake was discovered shortly after the administration of the dose when the technician noticed the name on the dose did not match that of the patient. The bone scan patient and cardiac patient had very similar sounding last names, which contributed to the error. The patient was notified of the error when he returned for his cardiac scan 45 minutes after injection. The actual bone scan patient was sent home without any scan and was not injected with any dose because they caught the error before he arrived for scanning. Event No.: WA 100041 |
| Where | |
|---|---|
| Walla Walla Clinic Walla Walla, Washington (NRC Region 4) | |
| License number: | MO23 |
| Organization: | Wa Division Of Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+35.6 h1.483 days <br />0.212 weeks <br />0.0488 months <br />) | |
| Opened: | Brandin Ketter 18:36 Jun 9, 2010 |
| NRC Officer: | Pete Snyder |
| Last Updated: | Jun 9, 2010 |
| 45996 - NRC Website | |
Walla Walla Clinic with Agreement State | |
WEEKMONTHYEARENS 459962010-06-08T07:00:0008 June 2010 07:00:00
[Table view]Agreement State Agreement State Report - Wrong Dose 2010-06-08T07:00:00 | |