ENS 46470

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v t e 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. * * RETRACTION FROM JOEL HASSIEN TO HUFFMAN AT 1549 EST ON 12/10/10 * * * After further review of the event described above, the licensee determined that the event was not reportable to the NRC Operations Center. The retraction is based on a determination that the dose to the organs involved did not exceed the reportability limits. The licensee will log the details of this event. R3DO (Daley) and FSME (Diaz-Torro) notified.

ENS 46470 +/- *RETRACTED*
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
v • d • e

v t e Emergency Notification System
Pipe County Memorial Hospital with 10 CFR 35.3045(a)(3)
WEEKMONTHYEAR2010-12-09T18:00:00 [Table view]
[ENS list for Pipe County Memorial Hospital]

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