ENS Event | |
|---|---|
20:45 Aug 21, 2013 | |
| Title | Agreement State Report - Patient Given Dose Prescribed for Another Patient |
| Event Description | The following was received from the State of Oregon via facsimile:
The inpatient was having an Adenosine Myoview stress test. The Nuclear Medicine Technologist took the dose that was already in the dose calibrator (place there earlier by another Nuclear Medicine Technologist). It measured about the same activity as 99m-Tc Myoview would measure in the dose calibrator. The Nuclear Medicine Technologist gave the patient 37.4 millicuries of 99m-Tc DTPA (lung ventilation dose) instead of 30 millicuries of 99m-Tc Myoview. The route of administration for 99m-Tc DTPA is inhalation and the route of administration for 99m-Tc Myoview is intravenous. The 99m-Tc DTPA was intended for a different patient. The patient was informed of the mistake and the stress test will be repeated tomorrow (8/22/13). The ordering physician was also notified of the event. There were no adverse effects to the patient, just delayed the study. This will be reported at the next Radiation Safety Committee Meeting along with any actions that will be taken to prevent this in the future. Oregon Event Number: 13-0031
This item is ready for closure. Incident closed. Not a reportable event. Notified R4DO (Gaddy).
The event was not reportable due to the fact that the total organ dose was less than 50 REM. Notified R4DO (Gaddy). 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 | |
|---|---|
| Good Samaritan Regional Medical Center Corvalis, Oregon (NRC Region 4) | |
| License number: | 90202 |
| Organization: | Or Dept Of Health Rad Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+17.8 h0.742 days <br />0.106 weeks <br />0.0244 months <br />) | |
| Opened: | Todd Carpenter 14:33 Aug 22, 2013 |
| NRC Officer: | Charles Teal |
| Last Updated: | Sep 5, 2013 |
| 49297 - NRC Website | |
Good Samaritan Regional Medical Center with Agreement State | |
WEEKMONTHYEARENS 492972013-08-21T20:45:00021 August 2013 20:45:00
[Table view]Agreement State Agreement State Report - Patient Given Dose Prescribed for Another Patient ENS 492062010-12-01T06:59:0001 December 2010 06:59:00 Agreement State Agreement State Report - Badge Exposure Exceeding 5 Rem Annual Dose Limit 2013-08-21T20:45:00 | |