ENS Event | |
|---|---|
06:00 Jan 15, 2021 | |
| Title | Wrong Radiopharmaceutical Used |
| Event Description | The following was received from Kansas Department of Health and Environment (KDHE) via email:
On January 21, 2021, the KDHE received an anonymous allegation that on January 15, 2021 a nuclear medical technician at Stormont Vail License 19-B420-02 injected 'MDP' [(Maronite Multidisc Kit)] into a stress test patient. This was the wrong radiopharmaceutical. There was a witness to the event (unnamed). The nuclear medical technologist did not report the misadministration to anyone. The individual communicating the allegation said they are a RSO in the community, and that they wished to remain anonymous. They also said Stormont Vail has an X-ray tech who is doing nuclear medicine and is not adequately trained. On the morning of January 22, 2021, a KDHE Environmental Specialist called the Director of Radiology concerning the event. The Director was made aware [by the licensee] of the incident this morning January 22, 2021 and was gathering details. They [the Director] informed KDHE that they were informed that on January 15, 2021 the patient was injected a second time with Technetium-99m-sestamibi. KDHE will conduct a full investigation on Monday, January 25, 2021. NMED ID No: KS210001 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 | |
|---|---|
| Stormont Vail Healthcare Inc Topeka, Kansas (NRC Region 4) | |
| License number: | 19-B420-02 |
| Organization: | Kansas Dept Of Health & Environment |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+178.45 h7.435 days <br />1.062 weeks <br />0.244 months <br />) | |
| Opened: | Aaron Short 16:27 Jan 22, 2021 |
| NRC Officer: | Thomas Herrity |
| Last Updated: | Jan 22, 2021 |
| 55081 - NRC Website | |
Stormont Vail Healthcare Inc with Agreement State | |
WEEKMONTHYEARENS 550812021-01-15T06:00:00015 January 2021 06:00:00
[Table view]Agreement State Wrong Radiopharmaceutical Used 2021-01-15T06:00:00 | |