ENS 52711
ENS Event | |
|---|---|
05:00 Apr 20, 2017 | |
| Title | Agreement State Report - Medical Event Due to Incorrect Nuclear Medical Scan Performed |
| Event Description | The following information was obtained from the state of Louisiana via email:
[On] April 21, 2017, [the licensee's RSO] called [Louisiana Department of Environmental Quality (LDEQ)] to inquire if one of his facilities had a 'Recordable Event' or if the facility had a 'Reportable Medical Event'. The event occurred under the Ochsner Clinic Foundation Broad Scope Medical License (OCFBS), LA-0002-L01. The event involved 2 mCi of I-131 being administered as an error when the PA [Physician Assistant] was ordering a medical test/scan. The test should have been one for the parathyroid, but a thyroid scan was ordered in error in the EPIC System [health informatics software]. [The] RSO for this licensee called in to see if the OMCBR [Ochsner Medical Center, Baton Rouge], Baton Rouge Medical Center error in administration had to be reported or just recorded for the OCFBS medical records. He was instructed it was a reportable event and he should investigate and make the appropriate corrective actions. The 2 mCi [of] I-131 was ordered and administered on [April] 18, 2017 and the error was discovered on April 20, 2017. The Nuclear Medicine Tech placed the patient on the table and the thyroid gland 'lit up' due to the I-131 uptake. According to [the RSO's] verbal report, the written orders were incomplete or did not exist; the parathyroid was the tissue to be scanned; and discovered on [April 20, 2017]. [The RSO] did a preliminary report on the phone April 21, 2017. His report gave an estimated target organ dose [of approximately] 600 rads to the thyroid. At that time, he stated there were additional aspects to be investigated, corrected, and reported. Corrective Action: The order capture procedure was changed recently and all of the Technologists, ordering Physicians, and Physician's Assistants will be re-trained in the current/new procedures. The wrong procedure was performed and the results will be sent to the referring physician. The patient was notified of the error. LDEQ considers this incident still open and subject to investigation and corrective action implementation. LA Event Report ID No.: LA-170006
The following information was obtained from the state of Louisiana via email: Investigated by LA: Preliminary: Phone Investigation Event was discovered by the wrong organ uptake for the patient scan to be performed. Facility findings wrong study ordered and wrong unit dose ordered and administered. Facility request a site visit when fact can be delivered and management can be present. Facility Investigation Visit, on 05/01/2017 Findings: PA ordered the unit dose without a written directive. PA ordered the scan through the OMCBR electronic order/records system. Patient was administered the I-131 and counselled when to return for the scan. [Patient] returned after numerous attempts to contact [patient]. The desired scan was different from the wrong scan ordered. At the scan time was when the ERROR was discovered. The wrong activity was ordered and administered due to electronic ordering and records system without confirmations of orders. Facility Calculations: from 2.0 mCi NaI-131 unit absorbed dose. 10% to 30% uptake from 2 mCi NaI-131. Absorbed Radiation Dose range to thyroid 1100 to 3200 rads with the thyroid gland dose approximately 1630 rads at 15.7 percent uptake from 1.65 NaI-131. State Confirmation From FDA Prescribing Dosage for NaI-131, Table 1, Absorbed Radiation Doses. Corrective Actions: 'PROOF' of EPIC electronic patients records system and for ordering studies Suspension of I-131 usage until system is corrected and staff training is complete Training for Written Physician's orders and ordering scans Confirming orders before administering drugs/isotopes NMED #170217 Notified R4DO (Rollins) and NMSS Events Notification by email. 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 | |
|---|---|
| Ochsner Medical Center Baton Rouge Baton Rouge, Louisiana (NRC Region 4) | |
| License number: | LA-0002-L01, |
| Organization: | Louisiana Radiation Protection Div |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+155.6 h6.483 days <br />0.926 weeks <br />0.213 months <br />) | |
| Opened: | Joseph Noble 16:36 Apr 26, 2017 |
| NRC Officer: | Howie Crouch |
| Last Updated: | Jun 8, 2017 |
| 52711 - NRC Website | |
Ochsner Medical Center Baton Rouge with Agreement State | |
WEEKMONTHYEARENS 527112017-04-20T05:00:00020 April 2017 05:00:00
[Table view]Agreement State Agreement State Report - Medical Event Due to Incorrect Nuclear Medical Scan Performed 2017-04-20T05:00:00 | |