ENS Event | |
|---|---|
05:00 Aug 25, 2022 | |
| Title | Diagnostic Misadministration |
| Event Description | The following information was provided by the Alabama Dept. of Public Health Office of Radiation Control via email:
[The licensee's] Representative stated that a patient was prescribed 20 milliCuries of sodium pertechnetate (did not state for which type of scan); the patient received 30 milliCuries of sestamibi (intended for a cardiac stress dose). The representative stated that the nuclear medicine tech that administered the wrong dose is new and has been counseled. This nuclear medicine tech will also be subject to increased oversight into the near future. Representative did not state that the patient will experience any side effects, nor if the patient has been counseled. The misadministration appears to result in an EDE of 876.9 mrem; the highest organ/tissue dose appears to be to the gall bladder wall with a dose of estimated 3663 mrem. Alabama Incident 22-14
Cause and Corrective Actions (State's and licensees' actions): The tech that administered the wrong dose was still in her orientation/training period. The licensee stated that the tech was counseled and will be under increased monitoring during her orientation period. Close-out report Notified NMSS DAY (Rivera-Cappella) and R1DO (Gray) and via email: NMSS Event Notification 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 | |
|---|---|
| Huntsville Hospital Health System Huntsville, Alabama (NRC Region 1) | |
| Organization: | Alabama Radiation Control |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+35.22 h1.468 days <br />0.21 weeks <br />0.0482 months <br />) | |
| Opened: | Cason Coan 16:13 Aug 26, 2022 |
| NRC Officer: | Bethany Cecere |
| Last Updated: | Sep 2, 2022 |
| 56071 - NRC Website | |
Huntsville Hospital Health System with Agreement State | |
WEEKMONTHYEARENS 560712022-08-25T05:00:00025 August 2022 05:00:00
[Table view]Agreement State Diagnostic Misadministration 2022-08-25T05:00:00 | |