ENS 54903

v t e ENS Event
19:00 Sep 16, 2020
Title		Agreement State Report - Incorrect Radionuclide Administered to a Patient
Event Description	The following was received from the state of Utah, Division of Waste Management and Radiation Control, via email: At approximately 1300 (MDT), on September 16, 2020, a Nuclear Medicine Technician injected 9.5 mCi of Tc-99 Sestamibi into the wrong patient. The prescribed radiopharmaceutical to be administered was Tc-99m MAA. The dose of Tc-99 Sestamibi was intended for a patient scheduled earlier in the day that did not show up for their appointment. The Nuclear Medicine Technician failed to swap out the Tc-99 Sestamibi for Tc-99m MAA for the 1300 MDT patient. State Event Report No.: Will be provided in a follow up report. 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 54903 +/-
Where
Utah Division Of Radiation Control Salt Lake City, Utah (NRC Region 4)
License number:	UT 1800253
Organization:	Utah Division Of Radiation Control
Reporting

Agreement State
Time - Person (Reporting Time:+-1 h-0.0417 days <br />-0.00595 weeks <br />-0.00137 months <br />)
Opened:	Phil Goble 18:00 Sep 16, 2020
NRC Officer:	Thomas Herrity
Last Updated:	Sep 16, 2020
54903 - NRC Website
v • d • e

v t e Emergency Notification System
Utah Division of Radiation Control with Agreement State
WEEKMONTHYEAR		Agreement State Report - Incorrect Radionuclide Administered to a Patient 2020-09-16T19:00:00 [Table view]
[ENS list for Utah Division of Radiation Control]

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