ENS Event | |
|---|---|
05:00 Apr 12, 2018 | |
| Title | Agreement State Report - Wrong Radiopharmaceutical Used |
| Event Description | The following is information received via e-mail:
April 19, 2018, [the licensee] called to inquire if one of his facilities had a 'Recordable Event' or if the facility had a 'Reportable Medical Event.' The report and attachments were left in a voice mail at 8:18 pm [CDT]. The event occurred under the [Slidell Memorial Hospital] SMH Therapeutic and Diagnostic Radioactive Material License, LA-0783-L02. The event involved 5.4 mCi Tc-99m-Myoview administered to a patient who was scheduled for a lung scan utilizing [approximately] 5.4 mCi Tc-99m-MAA. The technologist depended on the unit dose for 'STAT' used to be MAA and did not verify the unit dose label. This medical event occurred on 04/12/2018. The technologist states that a Myoview cardiac dose was in a pig labelled MAA for a lung scan. The pharmacy pulled the dose records, verified the bar coding and determined the technologist was at error. [The licensee] provided dose calculations for the heart scan dose utilizing 5.4 mCi Tc-99m-Myoview as 0.224 rad effective dose equivalent and highest organ dose of 0.972 rad to the wall of the gallbladder. There were corrective actions [to] retrain the technologist in patient dose verification prior to injection and request their pharmacy change their label fonts to magnification and bolding the unit dose labels. The referring physician and the patient were notified of the error. LDEQ [Louisiana Department of Environmental Quality] considers this incident still open and subject to investigation to determine if this event was caused by the facility personnel or if it is an error caused by the pharmacy personnel. Louisiana Event Report ID No.: LA-180007, T 184299 |
| Where | |
|---|---|
| Slidell Memorial Hospital Slidell, Louisiana (NRC Region 4) | |
| License number: | LA-0783-L02, |
| Organization: | Louisiana Radiation Protection Div |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+439.57 h18.315 days <br />2.616 weeks <br />0.602 months <br />) | |
| Opened: | Joe Noble 12:34 Apr 30, 2018 |
| NRC Officer: | Dong Park |
| Last Updated: | Apr 30, 2018 |
| 53369 - NRC Website | |
Slidell Memorial Hospital with Agreement State | |
WEEKMONTHYEARENS 533692018-04-12T05:00:00012 April 2018 05:00:00
[Table view]Agreement State Agreement State Report - Wrong Radiopharmaceutical Used 2018-04-12T05:00:00 | |