ENS Event | |
|---|---|
05:00 Mar 11, 2020 | |
| Title | Dose Misadministration |
| Event Description | The following information was received from the Alabama Department of Public Health Office of Radiation Control (the Agency) via email:
Issue discovered 6/30/2022, during inspection. The licensee did not report to the Agency at the time of occurrence. The dose to patient was evaluated as a result of a wrong dose on 7/8/2022. [On 3/11/2020,] the patient was prescribed 15 mCi of Tc-99m sestamibi/Cardiolite; the patient received 24.28 mCi of Tc-99m MDP [methyl diphosphonate]. The licensee reported that the nuclear medicine technician did not adequately verify dose labeling, and has been retrained in procedures. [This] appears to result in an effective dose of 512.068 mrem, and dose to bone surfaces of 5659.668 mrem. AL incident no.: 22-10
Cause and Corrective Actions (States and licensees' actions) Licensee reported that the nuclear medicine tech was advised to double check dose labels prior to patient dosing. Licensee also stated personnel were unaware of misadministration reporting requirements (misadministration found during Agency inspection). Event closed Notified NMSS DAY (Rivera-Cappella) and R1DO (Gray) and via email: NMSS Event Notification 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 | |
|---|---|
| Wiregrass Medical Center Geneva, Alabama (NRC Region 1) | |
| Organization: | Alabama Radiation Control |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+20388.93 h849.539 days <br />121.363 weeks <br />27.929 months <br />) | |
| Opened: | Cason Coan 17:56 Jul 8, 2022 |
| NRC Officer: | Brian Lin |
| Last Updated: | Sep 2, 2022 |
| 55986 - NRC Website | |
Wiregrass Medical Center with Agreement State | |
WEEKMONTHYEARENS 559862020-03-11T05:00:00011 March 2020 05:00:00
[Table view]Agreement State Dose Misadministration 2020-03-11T05:00:00 | |