ENS 47005

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v t e ENS Event
07:00 Dec 9, 2009
Title	Agreement State Report - Medical Event - Radiopharamaceutical Administered to Wrong Patient
Event Description	The following information was received via e-mail: On Wednesday, December 9, 2009, an 8 mCi dose of Tc-99m Sestamibi was administered via IV injection to an incorrect patient. The patient receiving the misinjection did not have a written order for the procedure in their medical chart. The event was reported to the RCP (Radiation Control Program) by telephone on Thursday December 10, 2009, as required in NRC 35.3045, 'Report and Notification of a Medical Event.' The misinjection was a result of the technologist failing to follow established written policy and procedure of verifying the patient I.D. with three identifiers: Name (patient spelling last name), DOB (verbalized by patient) and UMC Account Number and not using an interpreter as directed by policy. This procedure of patient identification has been established as a barrier to prevent such a situation from occurring. Failure to follow procedure is in direct violation of hospital policy and resulted in disciplinary action. The patient was immediately notified of the event. No adverse effect of the injection has been foreseen considering the activity of the radiopharmaceutical administered. The physician of the patient was also notified of the misinjection by telephone. The RSO has been notified of the misinjection and the details of the incident have been entered into the minutes of the radiation safety committee meeting for this quarter on December 10, 2009. This event is closed. Item Number: NV090001. 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 47005 +/-
Where
University Medical Center Las Vegas, Nevada (NRC Region 4)
License number:	03-12-0034-01
Organization:	Nv Div Of Rad Health
Reporting

Agreement State
Time - Person (Reporting Time:+13662.95 h569.29 days <br />81.327 weeks <br />18.716 months <br />)
Opened:	Sneha Ravikumar 12:57 Jul 1, 2011
NRC Officer:	Joe O'Hara
Last Updated:	Jul 1, 2011
47005 - NRC Website
v • d • e

v t e Emergency Notification System
University Medical Center with Agreement State
WEEKMONTHYEAR2009-12-09T07:00:00 [Table view]
[ENS list for University Medical Center]

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