ENS Event | |
|---|---|
04:00 Apr 22, 2015 | |
| Title | Agreement State Report - Bulk Dose Administered to Patient |
| Event Description | The following information was received from the Commonwealth of Massachusetts via email:
The licensee's Radiation Safety Officer (RSO) reported on April 23, 2015 that, on the morning of April 22, 2015, the licensee mistakenly administered to a patient the wrong radioactive drug, a 118 mCi Tc-99m bulk dose instead of the prescribed 12.9 mCi Tc-99m Sestamibi dose, at the licensee's Baystate Franklin Medical Center facility. The wrong radioactive drug administered was reported by the licensee's RSO to have resulted in 5.6 rem effective dose equivalent to the patient, a reportable medical event in accordance with 105 CMR 120.594(A)(1)(b)1. The licensee's RSO reported that the patient and the referring physician have been notified and that the RSO did not expect any harm to the patient. The RSO reported the cause included that proper procedures were not followed. The Agency (Massachusetts Radiation Control Program) plans to perform a special inspection and considers this event to be open. 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 | |
|---|---|
| Baystate Health Springfield, Massachusetts (NRC Region 1) | |
| License number: | 60-0095 |
| Organization: | Ma Radiation Control Program |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+53.37 h2.224 days <br />0.318 weeks <br />0.0731 months <br />) | |
| Opened: | Joshua Daehler 09:22 Apr 24, 2015 |
| NRC Officer: | Vince Klco |
| Last Updated: | Apr 24, 2015 |
| 51009 - NRC Website | |
Baystate Health with Agreement State | |
WEEKMONTHYEARENS 579112025-08-11T15:00:00011 August 2025 15:00:00
[Table view]Agreement State Lost I-125 Seed ENS 510092015-04-22T04:00:00022 April 2015 04:00:00 Agreement State Agreement State Report - Bulk Dose Administered to Patient 2025-08-11T15:00:00 | |