Narrative: On 7/21/2010 at 12:00 p.m at the Hot Lab: 17 yr old patient came in for MIRALUMA study. STD dose is 25 mCi of Tc-99m MIRALUMA. Based on patient weight, (105 lbs), pediatric dose is calculated at 17.5 mCi. IV was started by mammography technician. Nuclear medicine technician went to physician to notify about pediatric dose. At this time, mammography technician assayed dose at 24.0 mCi and injected patient.
Reported to the Nevada Radiation Control Program at around 3:00 p.m.
The event is NRC reportable under 10CFR35.3045, since it is a dose different from the prescribed dose. Since 10 CFR 35 has been adopted by the state, it is reportable under state requirements too.
Persons involved: Pediatric patient, mammography technician and nuclear medicine technician.
Corrective Actions: Communication and cross-checking correct dosing especially during pediatric procedures.
Root causes and contributing factors: Haste and the mammography technician not recognizing the fact that the patient was a pediatric patient.
Isotope Details: Tc-99m: 24.0 mCi.
Procedure administered: MIRALUMA study.
Dose intended: 17.5 mCi of Tc-99m
Dose Administered: 24.0 mCi of Tc-99m
Target organ: Breast
Patient Informed: N
% Dose Exceeds Prescribed: 37
Diagnostic Study: Breast (MIRALUMA study)
Radiopharmaceutical: Tc-99m MIRALUMA
Effect on Patient: UNKNOWN
Source/Radioactive Material: UNSEALED SOURCE RADIOPHARM
Manufacturer: Cardinal Health PSC
Model Number: 190
Nevada Report No.: NV100011
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.