ENS 51981

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v t e ENS Event
12:30 Jun 3, 2016
Title	Patient Administered the Wrong Byproduct Material
Event Description	The following was received via email: This is a report and notification of a medical event for Perry County Memorial Hospital, located in Perryville, Missouri, which occurred today June 3, 2016 at approximately 7:30 a.m. CST. This medical event is being reported as required under 10 CFR Part 35.3045 (a)(2)(i), administration of a wrong radioactive drug containing byproduct material resulting in an effective dose equivalent of greater than 0.05 Sv or 5 rem. At approximately 8:15 a.m. today, [The Diagnostic Radiological Physicist] received a call from Perry County Memorial Hospital, that one of his nuclear medicine technologists had inadvertently administered a 63 y/o female patient a bulk unit dose of approximately 128 mCi of Tc-99m Sodium Pertechnetate intravenously. This female patient was scheduled to receive a 25 mCi dose of Tc-99m Medronate intravenously for bone scintigraphy. Using a Tc-99m Sodium Pertechnetate package insert provided by the unit dose supplier, [the Diagnostic Radiological Physicist] estimated that the resultant effective dose equivalent to the patient will be approximately 0.06 Sv or 6 rem. The resultant highest dose to any organ or tissue is estimated to be approximately 27 rads, which would be to the patient's upper lower intestinal wall. The patient has been notified with regards to this medical event. In addition, the RSO [Radiation Safety Officer] / Authorized User for Perry County Memorial Hospital has also been notified. 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.

ENS 51981 +/-
Where
Perry County Memorial Hospital Perryville, Missouri (NRC Region 3)
License number:	24-17037-02
Organization:	Perry County Memorial Hospital
Reporting

10 CFR 35.3045(a)(2)
Time - Person (Reporting Time:+3.78 h0.158 days <br />0.0225 weeks <br />0.00518 months <br />)
Opened:	Kenneth Andrews 16:17 Jun 3, 2016
NRC Officer:	Dong Park
Last Updated:	Jun 3, 2016
51981 - NRC Website
v • d • e

v t e Emergency Notification System
Perry County Memorial Hospital with 10 CFR 35.3045(a)(2)
WEEKMONTHYEAR2016-06-03T12:30:00 [Table view]
[ENS list for Perry County Memorial Hospital]

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