ENS 46460

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v t e ENS Event
15:30 Dec 4, 2010
Title	Delivered Dose Greater than Prescribed Dose
Event Description	A patient was scheduled for a Tc-99m Myoview diagnostic cardiac resting perfusion study on 12/04/2010. Prescribed dosage was 10 mCi as noted on the departmental Prescribed Dosage List. These dosages are delivered as unit dose quantities along with Tc-99m in bulk quantity. Technetium-99m was delivered in bulk quantity in a syringe at approximately 0600 [EST] as 150 mCi calibrated for 1200 [EST]. At approximately 0900 [EST] a MAA kit was made by withdrawing 64 mCi from the bulk allotment. The nuclear medicine technologist inadvertently picked up the syringe at approximately 1030 [EST] containing Tc-99m as pertechnetate in bulk quantity (124.5 mCi) and without confirmatory assay in the dose calibrator injected the patient. As per 10 CFR 35.3045 (a)(1), the dose delivered differs from the prescribed dose by greater than 5 rem effective dose equivalent (EDE). However the upper large intestine (ULI) dose does not differ by more than 50 rads from the dose to be delivered from the prescribed dosage as follows: Prescribed Dosage (10 mCi) EDE: 0.481 rem Administered Dosage (31.4 mCi) EDE: 5.988 rem (Difference = 5.507 rem) ULI Dose from Prescribed Dosage (10 mCi) 2.109 rads ULI Dose From Administered Dosage (124.5 mCi) 26.257 rads (Difference = 24.148 rads) As per 10 CFR 35.3045 (a)(1)(ii), the administered dosage (124.5 mCi) differs from the prescribed dosage (10 mCi) by greater than the limit of 20%. The physician determined there was no adverse impact on the patient. 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.

ENS 46460 +/-
Where
Oakwood Annapolis Hospital Wayne, Michigan (NRC Region 3)
License number:	21-11457-02
Organization:	Oakwood Annapolis Hospital
Reporting

10 CFR 35.3045(a)(1)
Time - Person (Reporting Time:+47.32 h1.972 days <br />0.282 weeks <br />0.0648 months <br />)
Opened:	Piyush Pandya 14:49 Dec 6, 2010
NRC Officer:	Vince Klco
Last Updated:	Dec 6, 2010
46460 - NRC Website
v • d • e

v t e Emergency Notification System
Oakwood Annapolis Hospital with 10 CFR 35.3045(a)(1)
WEEKMONTHYEAR2010-12-04T15:30:00 [Table view]
[ENS list for Oakwood Annapolis Hospital]

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