ENS Event | |
|---|---|
17:00 Oct 16, 2015 | |
| Title | Agreement State Report - Patient Dosed with Wrong Organ Uptake Tag |
| Event Description | The following information was received from the state of Louisiana via email:
On October 19, 2015, the Radiology/Nuclear Medicine Manager, reported that on October 16, 2015 at 1200 hours0.0139 days <br />0.333 hours <br />0.00198 weeks <br />4.566e-4 months <br />, a PRN Licensed Nuclear Medicine Tech inadvertently dosed a patient with 25 mCi of Tc-99-MDP. The error was detected shortly after administration. The patient had physician's orders to have a cardiac scan utilizing 25 mCi of Tc-99-Tetrofosmin. The isotope activity was correct. However, the organ uptake tag was incorrect. The error resulted from the Nuclear Medicine Tech not using the patient two identifiers before administering the unit dose. The activity was correct for the unit dose, but the organ uptake tag was different. The facility employees were off and a PRN Tech was filling-in on that Friday. This Tech is used at the facility frequently when an essential employee is absent. He is no stranger to the work environment of the Facility/Licensee. The source was a 25 mCi Tc-99 unit dose. He performed the receipt procedures, unit dose assay, and utilized procedures to administer the isotope, but did not cross-reference the name on the unit dose with the individual who received the injection. This site is a Medical Institution. The unit doses are kept in a locked 'HOT' lab in the Nuclear Medicine Department. KLS Physics Consultants was called in the help with the reporting requirements. The Tech was counselled and retrained in the facility's procedures for patient identification and administration of radioactive materials for human in vivo imaging. "The patient will receive the correct unit dose and scan, 25 mCi Tc-99-Tetrofosmin, for a cardiac scan at a later date. Event Report ID No.: LA-150018, T166800 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 | |
|---|---|
| Ville Platte Medical Center, Llc Ville Platte, Louisiana (NRC Region 4) | |
| License number: | LA-2956-L01, |
| Organization: | Louisiana Radiation Protection Div |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+164.1 h6.838 days <br />0.977 weeks <br />0.225 months <br />) | |
| Opened: | Joe Noble 13:06 Oct 23, 2015 |
| NRC Officer: | Dong Park |
| Last Updated: | Oct 23, 2015 |
| 51493 - NRC Website | |
Ville Platte Medical Center, Llc with Agreement State | |
WEEKMONTHYEARENS 514932015-10-16T17:00:00016 October 2015 17:00:00
[Table view]Agreement State Agreement State Report - Patient Dosed with Wrong Organ Uptake Tag 2015-10-16T17:00:00 | |