ENS 54903: Difference between revisions
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{{ENS notification | {{ENS notification | ||
| event number = 54903 | | event number = 54903 | ||
| facility = | | facility = | ||
| Organization = Utah Division Of Radiation Control | | Organization = Utah Division Of Radiation Control | ||
| license number = UT 1800253 | | license number = UT 1800253 | ||
| Line 10: | Line 10: | ||
| utype = | | utype = | ||
| cfr = Agreement State | | cfr = Agreement State | ||
| emergency class = | | emergency class = Non Emergency | ||
| notification date = 09/16/2020 18:00 | | notification date = 09/16/2020 18:00 | ||
| notification by = Phil Goble | | notification by = Phil Goble | ||
| Line 16: | Line 16: | ||
| event date = 09/16/2020 13:00 MDT | | event date = 09/16/2020 13:00 MDT | ||
| last update date = 09/16/2020 | | last update date = 09/16/2020 | ||
| title = Agreement State Report - Incorrect Radionuclide Administered to a Patient | | title = <Td Align="Left" Scope="Row">Agreement State Report - Incorrect Radionuclide Administered to a Patient | ||
| event text = The following was received from the state of Utah, Division of Waste Management and Radiation Control, via email: | | event text = The following was received from the state of Utah, Division of Waste Management and Radiation Control, via email: | ||
At approximately 1300 (MDT), on September 16, 2020, a Nuclear Medicine Technician injected 9.5 mCi of Tc-99 Sestamibi into the wrong patient. The prescribed radiopharmaceutical to be administered was Tc-99m MAA. The dose of Tc-99 Sestamibi was intended for a patient scheduled earlier in the day that did not show up for their appointment. The Nuclear Medicine Technician failed to swap out the Tc-99 Sestamibi for Tc-99m MAA for the 1300 MDT patient. | At approximately 1300 (MDT), on September 16, 2020, a Nuclear Medicine Technician injected 9.5 mCi of Tc-99 Sestamibi into the wrong patient. The prescribed radiopharmaceutical to be administered was Tc-99m MAA. The dose of Tc-99 Sestamibi was intended for a patient scheduled earlier in the day that did not show up for their appointment. The Nuclear Medicine Technician failed to swap out the Tc-99 Sestamibi for Tc-99m MAA for the 1300 MDT patient. | ||
State Event Report No.: Will be provided in a follow up report. | State Event Report No.: Will be provided in a follow up report. | ||
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. | 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. | ||
| URL = https://www.nrc.gov/reading-rm/doc-collections/event-status/event/2020/20200925en.html#en54903 | | URL = https://www.nrc.gov/reading-rm/doc-collections/event-status/event/2020/20200925en.html#en54903 | ||
Latest revision as of 12:19, 15 January 2021
| Where | |
|---|---|
| Utah Division Of Radiation Control Salt Lake City, Utah (NRC Region 4) | |
| License number: | UT 1800253 |
| Organization: | Utah Division Of Radiation Control |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+-1 h-0.0417 days <br />-0.00595 weeks <br />-0.00137 months <br />) | |
| Opened: | Phil Goble 18:00 Sep 16, 2020 |
| NRC Officer: | Thomas Herrity |
| Last Updated: | Sep 16, 2020 |
| 54903 - NRC Website | |