Semantic search
Start date | Reporting criterion | Title | Event description | System | LER | |
---|---|---|---|---|---|---|
ENS 49037 | 14 May 2013 16:45:00 | Agreement State | Agreement State Report - Wrong Dose Administered to Patient | The following information was obtained from the State of Nevada via email: The patient was to undergo a HIDA (hepatobiliary) scan for abdominal pain (Tc-99m; 5mCi, abdomen), but given syringe for MDP (bone scan) (Tc-99m; 30mCi; bone). A wrong dose of Tc-99m (600% the prescribed dose) was administered to the patient due to human error. Corrective action: Better training in cross-checking and confirming patient identity with prescribed dose information. 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. Item Number: NV130006
This is with regard to the wrong dose administration that was reported yesterday. (The State of Nevada) heard back from the RSO regarding the Effective Dose Equivalent: What should have been administered was 5 mCi of HIDA (Mebrofenin) = (3E-02) x 5 rem = 0.15 rem. What was administered was 30 mCi of MDP = (2E-02) x 30 rem = 0.60 rem. So, this would not be reportable. Notified R4DO (Walker) and FSME Events Resource via E-mail. |