The following summary of information was provided by the licensee via phone and email:
On June 6, 2025, a technologist injected Tc-99m Pertechnetate into the nebulizer instead of Tc-99m DTPA (diethylene-triamine-pentaacetate) for a lung perfusion ventilation study. The patient was an 11-year-old child with a weight of 61 lbs. (27.72 kg). The nuclear medicine technologist grabbed the wrong syringe and did not verify the information on the label before injecting into the nebulizer. The technologist has been advised by the physician on the need to ensure the labeling is correct prior to injection or use and to verify that it contains the correct compound for the correct study. The patient's family and the referring physician have been notified.
Initial indications of patient dose was 63.9 rem whole body (due to Tc-99m pertechnetate) with an initially prescribed activity of 18 mCi (Tc-99m DTPA) to the lungs. No indication of acute blood changes or radiation sickness. The licensee does not intend to call REAC/TS.
- * * RETRACTION ON 06/10/25 AT 1435 EDT FROM DAVID RHOE TO KERBY SCALES * * *
The following information was provided by the licensee via phone and email:
The original dosimetry estimate has been revised and indicates no organ dose exceeds the 50 rem limit or the 5 rem effective dose. The dose that was reported as 63.9 Rem was meant to be for an organ dose and not whole body. After much assistance from the NRC staff, a revised dosimetry estimate has been performed.
The estimate was performed using the MIRDcalc program with the dose of 18 mCi Tc-99m for a 10-year-old female.
Notified R1DO (Warnek), NMSS (Allen), and NMSS Events Notification via 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.