ENS 49037

v t e ENS Event
16:45 May 14, 2013
Title	Agreement State Report - Wrong Dose Administered to Patient
Event Description	The following information was obtained from the State of Nevada via email: The patient was to undergo a HIDA [hepatobiliary] scan for abdominal pain (Tc-99m; 5mCi, abdomen), but given syringe for MDP [bone scan] (Tc-99m; 30mCi; bone). A wrong dose of Tc-99m (600% the prescribed dose) was administered to the patient due to human error. Corrective action: Better training in cross-checking and confirming patient identity with prescribed dose information. 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. Item Number: NV130006 * * RETRACTION FROM SNEHA RAVIKUMAR VIA E-MAIL ON 5/16/13 AT 1329 EDT * * * This is with regard to the wrong dose administration that was reported yesterday. [The State of Nevada] heard back from the RSO regarding the Effective Dose Equivalent: What should have been administered was 5 mCi of HIDA (Mebrofenin) = (3E-02) x 5 rem = 0.15 rem. What was administered was 30 mCi of MDP = (2E-02) x 30 rem = 0.60 rem. So, this would not be reportable. Notified R4DO (Walker) and FSME Events Resource via E-mail.

ENS 49037 +/- *RETRACTED*
Where
St. Mary'S Regional Medical Center Reno, Nevada (NRC Region 4)
License number:	16-12-0244-02
Organization:	Nv Div Of Rad Health
Reporting

Agreement State
Time - Person (Reporting Time:+24.15 h1.006 days <br />0.144 weeks <br />0.0331 months <br />)
Opened:	Sneha Ravikumar 16:54 May 15, 2013
NRC Officer:	Pete Snyder
Last Updated:	May 16, 2013
49037 - NRC Website
v • d • e

v t e Emergency Notification System
St. Mary'S Regional Medical Center with Agreement State
WEEKMONTHYEAR2013-05-14T16:45:00 [Table view]
[ENS list for St. Mary'S Regional Medical Center]

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