ENS Event | |
|---|---|
18:00 Dec 9, 2010 | |
| Title | Two Different Patients Received Incorrect Diagnosic Doses Due to Vial Mix-Up |
| Event Description | A representative of the licensee (the hospital rad tech) reported that two patients were administered doses of diagnostic Technetium-99m (Tc-99m) for the wrong organs due to a mixed-up of the dose vials. Specifically:
Patient #1 received a 25 millicurie Tc-99m dose for a bone scan instead of the prescribed 10 millicurie Tc-99m dose for a Hida scan (to the gall bladder). Shortly thereafter, Patient #2 received the 10 millicurie Tc-99m dose for a Hida scan instead of the prescribed 25 millicurie Tc-99m dose for a bone scan. Both errors were discovered when the actual diagnostic scans were performed. The patients, their physicians, and the RSO have been notified of this event. The licensee representative stated that there should be no harm to the patient from the incorrect administration. The cause of this event was reported to be insufficient verification that the proper vial had been selected for injection. Both vials were reported to be identical in appearance. 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.
|
| Where | |
|---|---|
| Pipe County Memorial Hospital Louisiana, Missouri (NRC Region 3) | |
| License number: | 24-32776-01 |
| Organization: | Pipe County Memorial Hospital |
| Reporting | |
| 10 CFR 35.3045(a)(3) | |
| Time - Person (Reporting Time:+0.08 h0.00333 days <br />4.761905e-4 weeks <br />1.09584e-4 months <br />) | |
| Opened: | Doug Sonnenberg 18:05 Dec 9, 2010 |
| NRC Officer: | Bill Huffman |
| Last Updated: | Dec 10, 2010 |
| 46470 - NRC Website | |
Pipe County Memorial Hospital with 10 CFR 35.3045(a)(3) | |
WEEKMONTHYEARENS 464702010-12-09T18:00:0009 December 2010 18:00:00
[Table view]10 CFR 35.3045(a)(3) Two Different Patients Received Incorrect Diagnosic Doses Due to Vial Mix-Up 2010-12-09T18:00:00 | |