ENS Event | |
|---|---|
05:00 Sep 3, 2021 | |
| Title | Radiopharmaceutical Misadministration |
| Event Description | The following information was received from the Alabama Department of Public Health Office of Radiation Control (the Agency) via email:
Licensee emailed 9/3/2021 that a patient received the wrong radiopharmaceutical. The patient was prescribed PYP [pyrophosphate] with 15 millicuries Tc-99m; the patient received 15 mCi of Tc-99m sodium pertechnetate. The licensee reported that the nuclear medicine technologist thought the dose was mislabeled, and administered 15 mCi of the sodium pertechnetate dose. The dose to the patient appeared to be 721.5 mrem effective dose. The writer did not report this matter to the NRC Headquarters Operations Officer at the time of occurrence. The matter has been reviewed during inspection on 3/7 and 3/9/2022, and the licensee appears to have implemented corrective actions. AL incident no.: 21-29 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 | |
|---|---|
| Southeast Health Dothan, Alabama (NRC Region 1) | |
| License number: | 448 |
| Organization: | Alabama Radiation Control |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+7405.28 h308.553 days <br />44.079 weeks <br />10.144 months <br />) | |
| Opened: | Cason Coan 18:17 Jul 8, 2022 |
| NRC Officer: | Brian Lin |
| Last Updated: | Jul 8, 2022 |
| 55987 - NRC Website | |
Southeast Health with Agreement State | |
WEEKMONTHYEARENS 559872021-09-03T05:00:0003 September 2021 05:00:00
[Table view]Agreement State Radiopharmaceutical Misadministration 2021-09-03T05:00:00 | |