The following information was received from the State of
Wisconsin via fax:
Wisconsin Department of Health Service (DHS) received notification by voicemail from the licensee on July 5, 2011 about an incident that occurred on June 30, 2011. A patient was to receive 25.6 mCi of Samarium-153 (Sm-153) for bone pain; but the patient received 14.8 mCi (58%) of the planned dose. During administration of the Sm-153 to the patient, the staff used a three-way stopcock connected to the IV line. The syringe containing the radioactive material was connected to the stopcock. During the procedure the syringe was mistakenly removed from the stopcock and a few drops of the radioactive materials dripped on the absorbent pad before a member of the staff reconnected the syringe. The event was reported to the RSO within minutes, and a voicemail was left with DHS the following day (July 1, 2011). The patient was notified the same day.
On July 6, 2011, DHS inspectors conducted a reactive inspection. The licensee is instituting corrective actions. The corrective actions are as follows: 1) Conduct a dry run before administration of doses. 2) Use syringe shields previously used by the hospital, which fits syringes better. 3) Inform the nuclear pharmacy to add saline to the radioactive materials, which serves two purposes; first, decrease the radioactive material per volume of total material in the syringe so that administrations to the patient contain small amounts of radioactive materials, and second, if there is a spill, there will be only a small quantity of radioactive material in the spill. The licensee will send DHS an official report of the incident within 15 working days.
WI Event #: WI110008
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.