ENS 45996

v t e 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

ENS 45996 +/-
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
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v t e Emergency Notification System
Walla Walla Clinic with Agreement State
WEEKMONTHYEAR2010-06-08T07:00:00 [Table view]
[ENS list for Walla Walla Clinic]

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