ENS 49686
ENS Event | |
|---|---|
05:00 Dec 27, 2013 | |
| Title | Agreement State Report - Nuclear Medicine Administered to Wrong Patient |
| Event Description | The following Agreement State Report was received via facsimile:
Notifications: York Hospital [a PA DEP licensee] left a voice message on Friday, December 27, 2013 after business hours; the voice message was reviewed by the South Central Regional Office on Monday, December 30, 2013. This is an immediate reporting event under 35.3045(a)(2)(iii). Event Description: On Friday, December 27, 2013 a nuclear medicine technologist at York Hospital injected the wrong patient with 500 microcuries (microCi) of indium-111 (ln-111) Oxine leukocyte (ln-111 Oxine WBC or ln-111 WBC). This was to be part of a radiolabeling leukocyte component procedure for another patient that was in an adjacent room. The nuclear medicine technologist noticed swelling at the injection site and notified a nurse. Physicians and patient were informed of the incident on December 27th. Additional information regarding the dimensions of the tissue volume affected by the extravasation has become available from non-nuclear imaging performed subsequent to the ln-111 WBC injection. The shallow dose to the skin was estimated to be approximately 210 rad (2.1 Gy). In addition, a request has been made for approval to conduct follow-up whole body imaging of the residual ln-111 in the patient's body, towards providing additional information utilizable in refining further the shallow and whole body dose estimate. CAUSE OF THE EVENT: Human error. The nuclear medicine technologist did not check the patient's wrist-band, nor did they correlate the name and birth date provided verbally from the wrong patient, as to being not the appropriate patient for the ln-111 WBC injection. ACTIONS: A reactive inspection by the PA DEP South Central Region took place on Monday, December 30th. The nuclear medicine technologist was immediately placed on administration leave by the licensee. Further investigations by PA DEP and the licensee are underway. PA Event Report ID No: PA130030 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 | |
|---|---|
| York Hospital York, Pennsylvania (NRC Region 1) | |
| License number: | PA-0010 |
| Organization: | Pa Bureau Of Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+107.58 h4.483 days <br />0.64 weeks <br />0.147 months <br />) | |
| Opened: | David J. Allard 16:35 Dec 31, 2013 |
| NRC Officer: | Dong Park |
| Last Updated: | Dec 31, 2013 |
| 49686 - NRC Website | |
York Hospital with Agreement State | |
WEEKMONTHYEARENS 543462019-10-23T04:00:00023 October 2019 04:00:00
[Table view]Agreement State Incorrect Brachytherapy Seed Set Used for Implantation ENS 496862013-12-27T05:00:00027 December 2013 05:00:00 Agreement State Agreement State Report - Nuclear Medicine Administered to Wrong Patient ENS 482182012-08-21T04:00:00021 August 2012 04:00:00 Agreement State Agreement State - Radiation Treatment Overdose Resulting from a Potential Generic Issue 2019-10-23T04:00:00 | |