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| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 51583 | 9 November 2015 06:00:00 | Agreement State | Agreement State Report - Radiopharmaceutical Dose Administered to Wrong Patient | The following information was provided by the State of Oklahoma via E-mail: On November 10, 2015, Saint Francis Health System (SFHS) notified the DEQ (Oklahoma Department of Environmental Quality) that, on November 9, 2015, a patient undergoing Sentinel Node Scintigraphy was accidently administered a radiopharmaceutical dose intended for another patient. The patient, who was supposed to receive a 0.5 mCi interstitial injection of Technetium-99m, instead received a 30 mCi dose of Tc-99m intended for another patient undergoing a bone scan. On November 20, 2015, we performed a reactive inspection of SFHS and spoke with the two technologists involved, both of whom were CNMTs (Certified Nuclear Medicine Technologist). According to the technologist who performed the Sentinel Node Scintigraphy (Tech A) these procedures were nearly always done in Surgery however, in this instance, the surgeon requested that the patient be injected and imaged in Nuclear Medicine first. Therefore, when (Tech A) arrived at work, (Tech A) retrieved the scintigraphy dose from the hot lab and placed it in the imaging room she intended to use. (Tech A) then went to get the patient, who had already been prepped for surgery and was in the pre-op ward. On the way she encountered the other technologist (Tech B), and told her that she was going to get the scintigraphy patient and that the first out-patient of the day, a bone scan, was waiting. Tech B misunderstood this to mean that Tech A was going to surgery to do the scintigraphy procedure there as usual. Tech B then retrieved the bone scan dose from the hot lab and, not noticing that the scintigraphy dose was already present, placed it in the same imaging room that Tech A intended to use. She then went to get the bone scan patient and began preparing them for the procedure. While Tech B was occupied with the bone scan patient, Tech A returned with the scintigraphy patient and placed her in the imaging room, but did not notice that two doses were now present. She then proceeded to inject the patient with the 30 mCi bone scan dose instead of the correct 0.5 mCi scintigraphy dose. It should be noted that SFHS procedures call for the technologist to verify the patient identity on the dose pig immediately before administering it, but Tech A failed to carry out this check. Immediately after she had administered the dose, Tech A discovered her error and notified the RSO. The patient was evaluated by the staff Authorized Medical Physicists who concluded that she was unlikely to experience any medical effects from the incident. It is unclear whether this incident meets the criteria in 10 CFR 35.3045(a)(2) because there are no internal dose models which are applicable to interstitial administrations such as this. However, since the possibility cannot be ruled out, we are proceeding on the assumption that this is a Medical Event. SFHS submitted a written report on the incident, as required by 10 CFR 35.3045(d), on November 22, 2015. 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. | ||
| ENS 51469 | 15 October 2015 15:30:00 | Agreement State | Oklahoma Agreement State Report - Package Received with External Contamination | The following information was received via email from the State of Oklahoma: The State of Oklahoma Department of Environmental Quality (DEQ) was notified by Saint Francis Health System (OK-07163-01) that they have received a package with removable contamination on the exterior. The dose rate when surveyed is reported at 70 mR/hr, the wipe count was 400,000 cpm. The package contained an unknown amount of Sirtex Y-90 SirSpheres. The microsphere container is reported to be intact, and it appears that the contamination was spilled on the package after it was closed. The licensee is analyzing the wipe on an MCA (multi channel analyzer) to determine if the contamination is Y-90 or another nuclide. The carrier who delivered the package is unknown at this time.
The following information was received via email from the State of Oklahoma: The contamination on the package has been identified as Tc-99m, not Y-90. The contamination was limited to a (common carrier shipping) label applied to the package at the (common carrier) facility in Boston, MA. The package was transported from Boston to Dallas, TX by (common carrier airline), then by truck from Dallas to Saint Francis. The trucking company was contacted by the licensee and the truck driver was scanned at a local hospital in Dallas yesterday; results were negative. Wipe tests of the interior of the package confirm no contamination. The package was surveyed today by DEQ inspectors and the dose rate was 2 Mr/hr. The package is being held for decay in storage at the licensee facility. Notified R4DO (Miller) and NMSS Events Notification group via email. |