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| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 41031 | 7 September 2004 07:00:00 | Agreement State | Washington State Agreement State Report - Medical Misadministration | The following information was received from Washington State Department of Health: This is notification of an event in Washington State as reported to or investigated by the WA Department of Health, Office of Radiation Protection. STATUS: new Licensee: Saint Mary Medical Center City and State: Walla Walla, Washington License Number: WN-M0101-1 Type of License: Medical Combination Date of Event: September 7, 2004 Location of Event: Licensees facility in Walla Walla, Washington ABSTRACT: (where, when, how, why; cause, contributing factors, corrective actions, consequences, Dept. of Health (DOH) on-site investigation; media attention): The licensee's radiation safety officer notified the department that licensee staff had observed an anomaly after injecting a patient with Technetium (Tc) 99m, intended for a bone scan study. They had injected the proper patient with the apparent proper dose of 37.4 millicuries, Tc-99mHDP. When the patient returned approximately three hours later for the study, the patient showed no bone uptake but did have uptake in the liver and cardiac muscle. Two unit doses were received on September 3rd from the nuclear pharmacy for two different patients. Both patients were injected on the same day. The second patient showed a nominal bone uptake and the study was performed per procedure. The shipping documents and dose calibrator check indicated the dose was as ordered. The nuclear pharmacy was called and asked about the doses. The two doses had been drawn-up consecutively by the same pharmacist. The pharmacy was certain the order had been drawn, delivered and documented accurately. The licensee and pharmacy were unable to explain the anomalous first study. All information appears to corroborate that the study should have been as expected. A repeat scan was performed. This dose localized as expected and the study gave diagnostic quality images. On-site investigation by the department is not planned. No media attention noted. Notification Reporting Criteria: 10 CFR Part 35.33(a) Isotope and Activity involved: Technetium (Tc) 99mHDP, 37.4 mCi Overexposures? (number of workers/members of the public; dose estimate; body part receiving dose; consequence): Liver and Cardiac Muscle, dose estimate to be determined, the licensee indicated that the patient should receive adverse consequences as a result of the anomaly. Lost, Stolen or Damaged? (mfg., model, serial number): N/A Disposition/recovery: A second study was ordered and performed as expected. Leak test? N/A Vehicle: N/A Release of activity? N/A Activity and pharmaceutical compound intended: 37.4 mCi, Tc-99mHDP Misadministered activity and/or compound received: (as far as could be determined) 37.4 mCi, Tc-99mHDP Device (HDR, etc.) Mfg., Model; computer program: N/A Exposure (intended/actual); consequences: It is anticipated that the patient will receive no adverse health effect from the anomalous dose. Was patient or responsible relative notified? Both were notified. Was written report provided? Yes, dated September 8, 2004. Was referring physician notified? Yes Consultant used? No This event is assigned Washington event number WA-04-053 and is entered in NMED. |