ENS Event | |
|---|---|
12:00 May 17, 2012 | |
| Title | Medical Event - Patient Injected with Wrong Radiopharmaceutical and Quantity |
| Event Description | A patient scheduled for a lymphoscintigraphy procedure was incorrectly injected with 25 milliCuries of Tc-99M Medronate instead of the prescribed 3 milliCuries of Tc-99 Sulphur Colloid. The cause of the event was human error. The patient and physician have been notified. The physician believes there will be no long term adverse effects due to this error. In order to prevent reoccurrence, the nuclear medicine staff will add this event to staff training to ensure that staff double check the label and the dosage and drug. Other options are still being assessed.
The licensee also notified NRC Region 3 (Bob Gattone). 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 | |
|---|---|
| University Of Michigan Hospital Ann Arbor, Michigan (NRC Region 3) | |
| License number: | 21-00215-04 |
| Organization: | University Of Michigan Hospital |
| Reporting | |
| 10 CFR 35.3045(a)(1) | |
| Time - Person (Reporting Time:+124.58 h5.191 days <br />0.742 weeks <br />0.171 months <br />) | |
| Opened: | Mark Driscoll 16:35 May 22, 2012 |
| NRC Officer: | Joe O'Hara |
| Last Updated: | May 22, 2012 |
| 47946 - NRC Website | |
University Of Michigan Hospital with 10 CFR 35.3045(a)(1) | |
WEEKMONTHYEARENS 536952018-10-25T04:00:00025 October 2018 04:00:00
[Table view]10 CFR 35.3045(a)(1) Medical Event - Underdose ENS 479462012-05-17T12:00:00017 May 2012 12:00:00 10 CFR 35.3045(a)(1) Medical Event - Patient Injected with Wrong Radiopharmaceutical and Quantity ENS 466652011-03-09T15:00:0009 March 2011 15:00:00 10 CFR 35.3045(a)(1) Medical Event Involving Administration of Greater than Ordered Dose ENS 454362009-10-14T21:00:00014 October 2009 21:00:00 10 CFR 35.3045(a)(1) Patient Received Approximately 76% of the Prescribed Dose 2018-10-25T04:00:00 | |