ENS 50638

v t e ENS Event
05:00 Nov 24, 2014
Title	Agreement State Report - Medical Misadministration
Event Description	The following was received via email: A patient arrived for a rest/stress imaging procedure on 11/24/14. The rest dose was written to be 8 mCi Tc-99m, and the stress dose was written to be 24 mCi Tc-99m. The patient received the rest dose as written and the scan was performed. The patient was then to receive the 24 mCi stress dose, but instead received a 5 mCi stress dose (same drug, but only 21% of the intended activity) that was intended as the rest dose for another patient. Once the error was discovered, the patient was informed of the error and sent home with the intention of rescheduling the procedure at a later date. The licensee will submit the 15 day report to VRMP [Virginia Radioactive Materials Program] at which time the corrective actions will be reviewed and verified during their next inspection. Virginia Incident #: VA-14-23 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. * * RETRACTION ON 11/25/14 AT 1637 EST FROM MIKE WELLING TO DONG PARK * * * This report is being retracted, because it does not meet 10CFR35.3045 criteria. Notified R1DO (Noggle) and NMSS Events Notification via email.

ENS 50638 +/- *RETRACTED*
Where
Carillion Clinic Roanoke, Virginia (NRC Region 1)
License number:	770-051-1
Organization:	Virginia Rad Materials Program
Reporting

Agreement State
Time - Person (Reporting Time:+34.52 h1.438 days <br />0.205 weeks <br />0.0473 months <br />)
Opened:	Mike Welling 15:31 Nov 25, 2014
NRC Officer:	Daniel Mills
Last Updated:	Nov 26, 2014
50638 - NRC Website
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v t e Emergency Notification System
Carillion Clinic with Agreement State
WEEKMONTHYEAR2014-11-24T05:00:00 [Table view]
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