ENS 53434
ENS Event | |
|---|---|
06:00 Apr 4, 2018 | |
| Title | Agreement State Report - Patient Skin Contaminated with Flourine-18 |
| Event Description | The following summary was received from the North Dakota Department of Health via telephone:
On April 4, 2018 the licensee reported that a patient undergoing a PET (Positron Emission Tomography) scan was squirted with 15 millicuries of FDG (Fluorodeoxyglucose) - Flourine-18, by the technologist administering the dose. A peak skin dose of 2 Gray was calculated by the licensee Radiation Safety Officer. The North Dakota Department of Health is awaiting additional information from the licensee regarding the event. 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.
On April 4, 2018 a patient was imaged with ~15 millicuries of FDG. At the time of the injection, it is now believed that ~15 millicuries dose was inadvertently delivered on the patient's shirt. Since the first dose wasn't administered as intended, a second ~15 millicuries dose was administered into the patient. Per protocol the patient rested for an hour and was imaged. The patient was released from the scan room and was discharged and went to the cafeteria. The [study] physician reviewed the images and found them non-diagnostic due to external contamination. The [study] physician ordered that the images be repeated. The patient was located in the cafeteria and returned to Nuclear Medicine and his shirt was removed. Patient was reimaged approximately an hour after the start of the first scan (approximately 2 hours2.314815e-5 days <br />5.555556e-4 hours <br />3.306878e-6 weeks <br />7.61e-7 months <br /> after the shirt was contaminated) and the second set of images were deemed to be diagnostic. On May 15, 2018 the RSO [Radiation Safety Officer] learned of the event and began an investigation. The skin dose is estimated to be approximately 2.8 Gy to 100 cm2 of tissue. This exposed tissue was on the patient's torso. The uncertainty in the skin dose calculation is great. Due to the complexity of the calculation, the skin dose was estimated on May 31, 2018. The study physician is aware of the incident and will notify the referring physician. The patient is unlikely to have noticeable negative effects from the incident, however if the patient did have a tissue reaction, it would have been mild and transient. The patient has not yet been notified of any of the findings since the RSO was made aware, however the patient was aware that he was spilled on and that his shirt was kept for decay. Notice will be sent to the patient offering the ability to obtain a written description of the event. Continued investigation is in process and will start with a review of reporting requirements and event management related to radioactive spills. Notified the R4DO (Farnholtz), INES (Milligan), and the NMSS Events Notification email group. 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 | |
|---|---|
| Sanford Medical Center Fargo, North Dakota (NRC Region 4) | |
| License number: | ND 33-10227-02 |
| Organization: | North Dakota Department Of Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+1375.98 h57.333 days <br />8.19 weeks <br />1.885 months <br />) | |
| Opened: | Brooke Olson 13:59 May 31, 2018 |
| NRC Officer: | Jeff Herrera |
| Last Updated: | Jun 1, 2018 |
| 53434 - NRC Website | |
Sanford Medical Center with Agreement State | |
WEEKMONTHYEARENS 551452021-03-18T06:00:00018 March 2021 06:00:00
[Table view]Agreement State Medical Event (Incorrect Dose Location) ENS 534342018-04-04T06:00:0004 April 2018 06:00:00 Agreement State Agreement State Report - Patient Skin Contaminated with Flourine-18 2021-03-18T06:00:00 | |