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| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 43881 | 3 January 2008 15:30:00 | 10 CFR 35.3045(a)(2) | Administration of a Dose to the Wrong Individual | The 1st technologist went to standardized waiting room to call for a patient by their first name only. An older gentleman answered and was taken to the radiology lab where the 2nd technologist administered an IV with 7 millicuries of Cholotec (Tc-99). The patient was instructed about the test and when the patient was taken to the Radiologist, it was noticed that they had administered the dose to the wrong patient. The unintended patient had the same first name as the scheduled intended patient. After the error was discovered, the unintended patient was made aware of the mistake. The intended patient was found later and administered the prescribed dose. The RSO was notified and the physician determined that their will be no unintended permanent functional damage to an organ or a physiological system. The licensee plans to perform better screening of patients (using first and last names, SSN, and DOB, by both technologists) to prevent recurrence. 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. |