ENS 51583
ENS Event | |
|---|---|
06:00 Nov 9, 2015 | |
| Title | Agreement State Report - Radiopharmaceutical Dose Administered to Wrong Patient |
| Event Description | The following information was provided by the State of Oklahoma via E-mail:
On November 10, 2015, Saint Francis Health System [SFHS] notified the DEQ [Oklahoma Department of Environmental Quality] that, on November 9, 2015, a patient undergoing Sentinel Node Scintigraphy was accidently administered a radiopharmaceutical dose intended for another patient. The patient, who was supposed to receive a 0.5 mCi interstitial injection of Technetium-99m, instead received a 30 mCi dose of Tc-99m intended for another patient undergoing a bone scan. On November 20, 2015, we performed a reactive inspection of SFHS and spoke with the two technologists involved, both of whom were CNMTs [Certified Nuclear Medicine Technologist]. According to the technologist who performed the Sentinel Node Scintigraphy (Tech A) these procedures were nearly always done in Surgery however, in this instance, the surgeon requested that the patient be injected and imaged in Nuclear Medicine first. Therefore, when [Tech A] arrived at work, [Tech A] retrieved the scintigraphy dose from the hot lab and placed it in the imaging room she intended to use. [Tech A] then went to get the patient, who had already been prepped for surgery and was in the pre-op ward. On the way she encountered the other technologist (Tech B), and told her that she was going to get the scintigraphy patient and that the first out-patient of the day, a bone scan, was waiting. Tech B misunderstood this to mean that Tech A was going to surgery to do the scintigraphy procedure there as usual. Tech B then retrieved the bone scan dose from the hot lab and, not noticing that the scintigraphy dose was already present, placed it in the same imaging room that Tech A intended to use. She then went to get the bone scan patient and began preparing them for the procedure. While Tech B was occupied with the bone scan patient, Tech A returned with the scintigraphy patient and placed her in the imaging room, but did not notice that two doses were now present. She then proceeded to inject the patient with the 30 mCi bone scan dose instead of the correct 0.5 mCi scintigraphy dose. It should be noted that SFHS procedures call for the technologist to verify the patient identity on the dose pig immediately before administering it, but Tech A failed to carry out this check. Immediately after she had administered the dose, Tech A discovered her error and notified the RSO. The patient was evaluated by the staff Authorized Medical Physicists who concluded that she was unlikely to experience any medical effects from the incident. It is unclear whether this incident meets the criteria in 10 CFR 35.3045(a)(2) because there are no internal dose models which are applicable to interstitial administrations such as this. However, since the possibility cannot be ruled out, we are proceeding on the assumption that this is a Medical Event. SFHS submitted a written report on the incident, as required by 10 CFR 35.3045(d), on November 22, 2015. 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 | |
|---|---|
| Saint Francis Health System Tulsa, Oklahoma (NRC Region 4) | |
| License number: | OK-07163-01 |
| Organization: | Ok Deq Rad Management |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+562.22 h23.426 days <br />3.347 weeks <br />0.77 months <br />) | |
| Opened: | Kevin Sampson 16:13 Dec 2, 2015 |
| NRC Officer: | Jeff Rotton |
| Last Updated: | Dec 2, 2015 |
| 51583 - NRC Website | |
Saint Francis Health System with Agreement State | |
WEEKMONTHYEARENS 515832015-11-09T06:00:0009 November 2015 06:00:00
[Table view]Agreement State Agreement State Report - Radiopharmaceutical Dose Administered to Wrong Patient ENS 514692015-10-15T15:30:00015 October 2015 15:30:00 Agreement State Oklahoma Agreement State Report - Package Received with External Contamination 2015-11-09T06:00:00 | |