ENS 43432
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ENS Event | |
|---|---|
05:00 May 16, 2007 | |
| Title | Louisiana Agreement State Report - Medical Event Due to Dispensing Error |
| Event Description | The State provided the following information via facsimile:
Description of Event - A customer called the [Cardinal Health] pharmacy on Wednesday, May 16, 2007 to report that the late injection of Tc-99m sestamibi, a heart imaging agent, showed no heart uptake on the film. Instead there was only soft tissue uptake. The activity dispensed and injected matched the prescription. The next day the patient was brought back to the department and the image indicated that the dose injected was Tc-99m medronate, a bone imaging agent. Investigation and Root Causes - A large dose of Tc-99m sestamibi was ordered at 0600 calibrated for 1400. A biliary dose was also ordered at the same time. These were the only two doses drawn at that time. After notification by the hospital, an investigation revealed that the activity and volume remaining in the sestamibi vial plus the volume and activity dispensed matched the total volume and activity of the prepared kit (after correction for decay). The concentration for the sestamibi kit is normally 30% greater than for a bone imaging kit. Since the volume was correct, no flags were detected during dispensing. It is not Cardinal Health policy to test used syringes due to blood borne pathogen hazards. No other clients that were dispensed doses from the same vial reported errors in imaging. From this analysis, Cardinal Health can find no errors on its part to account for the imaging error. Actions Taken to Prevent a Recurrence - Cardinal Health has protocols in place to prevent dispensing errors of the type described above. Since the error cannot be attributed to Cardinal Health, corrective action is unnecessary. LA event Report ID No.: LA070015 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 West Monroe, Louisiana (NRC Region 4) | |
| License number: | LA-5119-L01 |
| Organization: | Louisiana Radiation Protection Div |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+825.62 h34.401 days <br />4.914 weeks <br />1.131 months <br />) | |
| Opened: | Richard Penrod 14:37 Jun 19, 2007 |
| NRC Officer: | Jeff Rotton |
| Last Updated: | Jun 19, 2007 |
| 43432 - NRC Website | |
Cardinal Health with Agreement State | |
WEEKMONTHYEARENS 569692024-02-05T14:00:0005 February 2024 14:00:00
[Table view]Agreement State Lost Source ENS 566272023-07-10T04:00:00010 July 2023 04:00:00 Agreement State Eluate Exceeded Mo-99 Limit ENS 558812022-05-05T14:45:0005 May 2022 14:45:00 Agreement State Transportation Event ENS 543572019-10-29T08:15:00029 October 2019 08:15:00 Agreement State Agreement State Report - Stolen Sources ENS 542252019-08-14T17:00:00014 August 2019 17:00:00 Agreement State Agreement State Report - Vehicle Accident During Radiopharmaceutical Transport ENS 539312019-02-26T04:00:00026 February 2019 04:00:00 Agreement State Agreement State Report - Mo-99/Tc-99 Breakthrough Limit Exceeded. 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 2024-02-05T14:00:00 | |
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