ENS Event | |
|---|---|
15:30 Apr 4, 2021 | |
| Title | Patient Receives Wrong Dose |
| Event Description | The following is a summary from a phone call and subsequent e-mail from the technologist at the Good Samaritan Hospital in Vincennes, Indiana:
On Sunday, April 4th, 2021 at approximately 1130 EDT, a reportable event occurred when the technologist was called in to administer injections for two patients. The first patient was to have a lung scan. Instead of injecting the patient with Tc99m MAA for a lung perfusion, the technologist injected him with Tc99m Choletec that was to be used for the second patient. Both the lung dose and the gallbladder dose were calibrated for the same time and both were 5 mCi doses. The technologist picked up the wrong dose but did not double check the syringe sticker before administration. The patient suffered no visible harm and picked up an additional exposure from the 5.23 mCi of Tc99m Choletec and a delay in completing the exam since pictures would not be diagnostic if done before the choletec has had the chance to dissipate. The technologist notified the NRC Operations Center and completed an incident report for the hospital. The technologist plans to notify her supervisor, the Radiation Safety Officer, the patient's nurse, patient, and radiologist.
On further evaluation, this event did not meet reportability requirements. Notified R3DO (Pelke), NMSS (Williams), and NMSS Events Notification (by email) 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 | |
|---|---|
| Good Samaritan Hospital Vincennes, Indiana (NRC Region 3) | |
| License number: | 13-01787-01 |
| Organization: | Good Samaritan Hospital |
| Reporting | |
| 10 CFR 35.3045(a)(1) | |
| Time - Person (Reporting Time:+-0.55 h-0.0229 days <br />-0.00327 weeks <br />-7.5339e-4 months <br />) | |
| Opened: | Brook Strahle 14:57 Apr 4, 2021 |
| NRC Officer: | Brian P. Smith |
| Last Updated: | Apr 5, 2021 |
| 55170 - NRC Website | |
Good Samaritan Hospital with 10 CFR 35.3045(a)(1) | |
WEEKMONTHYEARENS 551702021-04-04T15:30:0004 April 2021 15:30:00
[Table view]10 CFR 35.3045(a)(1) Patient Receives Wrong Dose 2021-04-04T15:30:00 | |