ENS 43841
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ENS Event | |
|---|---|
15:13 Nov 19, 2007 | |
| Title | Agreement State Report - Dose to Wrong Organs |
| Event Description | The Agreement State of Louisiana submitted the following information:
On Monday November 19, 2007, Cardinal Health Nuclear Pharmacy delivered an isotope dose labeled incorrectly. The dose delivered, was labeled Tc-99m Mertiatide (Mag-3) assayed at 5.1 milliCuries at 9:13 AM. The dose ordered was for a Renal Scan scheduled for 9:30 AM. After injection of the ordered dose, subsequent imaging revealed accumulation of radiopharmaceutical in the liver and spleen. The target organ for Mag-3 is the kidneys. The images would suggest Tc-99m Sulfur Colloid as the agent delivered. This information was reported by the facility that received the dose. The facility also notified Cardinal Health. This matter is under investigation by Louisiana DEQ. This report refers to Louisiana event identification number: LA070030. 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. |
| Where | |
|---|---|
| Cardinal Health Baton Rouge, Louisiana (NRC Region 4) | |
| License number: | La-5394-L01 |
| Organization: | Louisiana Radiation Protection Div |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+593.38 h24.724 days <br />3.532 weeks <br />0.813 months <br />) | |
| Opened: | Richard Penrod 08:36 Dec 14, 2007 |
| NRC Officer: | Pete Snyder |
| Last Updated: | Dec 14, 2007 |
| 43841 - NRC Website | |
Cardinal Health with Agreement State | |
WEEKMONTHYEARENS 573482024-09-27T09:00:00027 September 2024 09:00:00
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ENS 533592018-04-23T04:00:00023 April 2018 04:00:00 Agreement State Agreement State Report - Stolen Technicium-99 ENS 526592017-03-22T04:00:00022 March 2017 04:00:00 Agreement State Agreement State Report - Package Lost During Shipment ENS 526172017-03-17T11:00:00017 March 2017 11:00:00 Agreement State Agreement State Report - Transportation Accident Damaging Licensed Material ENS 519712016-06-01T05:00:0001 June 2016 05:00:00 Agreement State Agreement State Report - Two Radioactive Materials Packages Not Located After Carrier Accident ENS 509202015-03-01T04:00:0001 March 2015 04:00:00 Agreement State Agreement State Report - Radiation Technician Potential Overexposure ENS 504812014-08-27T07:00:00027 August 2014 07:00:00 Agreement State Agreement State Report - Radioactive Material Release Exceeding Emission Limit ENS 496752013-12-06T05:00:0006 December 2013 05:00:00 Agreement State Agreement State Report - Licensed Material Recovered at a Landfill ENS 494022013-09-23T04:00:00023 September 2013 04:00:00 Agreement State Agreement State Report - Radiopharmaceutical Worker Received >50 Rem to Both Hands ENS 475602011-12-21T08:00:00021 December 2011 08:00:00 Agreement State Agreement State Report - Iodine-125 Brachytherapy Seed Missing from Transportation Package ENS 465662010-12-28T06:00:00028 December 2010 06:00:00 Agreement State Agreement State Report - Transportation Accident Involving Radiopharmaceuticals ENS 464512010-12-02T11:20:0002 December 2010 11:20:00 Agreement State Agreement State Report - Employee Contaminations During Cyclotron Operation ENS 453422009-09-11T09:30:00011 September 2009 09:30:00 Agreement State Agreement State Report - Contaminated Pharmacy Shipment Package ENS 453632009-07-21T04:00:00021 July 2009 04:00:00 Agreement State Agreement State - Potential Extremity Overexposure ENS 443072008-06-13T08:00:00013 June 2008 08:00:00 Agreement State Agreement State Report Involving a Vehicle Transporting Radioactive Material ENS 442642008-06-03T05:00:0003 June 2008 05:00:00 Agreement State Agreement State Report - Radiopharmaceuticals Delivery Vehicle Accident ENS 441362008-04-09T12:00:0009 April 2008 12:00:00 Agreement State Agreement State - Mississippi - Traffic Accident Involving Truck Carrying Tc-99M ENS 441392008-03-19T04:00:00019 March 2008 04:00:00 Agreement State Agreement State - Florida - Missing Dose of Tc-99M ENS 438412007-11-19T15:13:00019 November 2007 15:13:00 Agreement State Agreement State Report - Dose to Wrong Organs ENS 437312007-09-24T05:00:00024 September 2007 05:00:00 Agreement State Agreement State Report Involving an Improper Injection ENS 434322007-05-16T05:00:00016 May 2007 05:00:00 Agreement State Louisiana Agreement State Report - Medical Event Due to Dispensing Error ENS 432012007-02-14T06:00:00014 February 2007 06:00:00 Agreement State Agreement State Report - Dispensing Error for Thallium -201 Dose ENS 429992006-11-16T06:00:00016 November 2006 06:00:00 Agreement State Agreement State - Stolen Truck Containing Radiopharmiceuticals ENS 428582006-09-22T11:00:00022 September 2006 11:00:00 Agreement State Agreement State Report - Traffic Accident Involving a Truck Carrying Radioactive Material ENS 426242006-05-22T05:00:00022 May 2006 05:00:00 Agreement State Agreement State Report - Unsecured Delivery of Radioactive Material ENS 424412006-03-22T08:00:00022 March 2006 08:00:00 Agreement State Agreement State Report - Radiation Exposure ENS 424182006-03-05T06:00:0005 March 2006 06:00:00 Agreement State Agreement State Report - Patient Received Improper Medical Dose ENS 422732006-01-18T06:00:00018 January 2006 06:00:00 Agreement State Agreement State Report of an Extremity Exposure Greater than Limit ENS 422362005-12-29T16:45:00029 December 2005 16:45:00 Agreement State Agreement State Report - Transportation Accident Involving Used Technetium 99M Syringes ENS 422232005-12-22T12:30:00022 December 2005 12:30:00 Agreement State Agreement State Report of Traffic Accident Involving Radioactive Material ENS 418402005-06-26T21:20:00026 June 2005 21:20:00 Agreement State Agreement State - Medical Sources Stolen ENS 414692005-03-08T13:40:0008 March 2005 13:40:00 Agreement State Agreement State Report - Truck Containing Radiopharmaceuticals Stolen in Massachusetts ENS 413512005-01-20T17:00:00020 January 2005 17:00:00 Agreement State Agreement State Report Involving a Pharmacy Spill of Samarium-153 ENS 413062005-01-01T10:00:0001 January 2005 10:00:00 Agreement State Agreement State Report of Truck Crash Resulting in Minor Contamination and Loss of Radiopharmaceutical Vials ENS 412712004-10-25T20:00:00025 October 2004 20:00:00 Agreement State Agreement State Medical Event ENS 409362004-08-09T13:30:0009 August 2004 13:30:00 Agreement State Spill of I-131 Resulting in Contamination ENS 418332004-05-02T04:00:0002 May 2004 04:00:00 Agreement State Agreement State Report Involving a Potential Extremity Overexposure ENS 408482004-02-27T05:00:00027 February 2004 05:00:00 Agreement State Lousiana Agreement State Report - Medical Event ENS 405532004-02-26T21:00:00026 February 2004 21:00:00 Agreement State Agreement State Reports Spill at Nuclear Pharmacy 2024-09-27T09:00:00 | |
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