ENS Event | |
|---|---|
05:00 Mar 14, 2023 | |
| Title | Medical Event |
| Event Description | The following information was received via email:
On March 21, 2023, a report of misadministration was received by the Arkansas Department of Health from Baptist Health Medical Center, Little Rock at 0945 CDT. A 72 year old female came to the Baptist Health Little Rock Nuclear Medicine department for a radioactive iodine thyroid scan. The patient had been scheduled in our [Electronic Medical Record system] as a Total Body Iodine [TBI] Scan with Thyrogen. The patient was given the first dose of Thyrogen on Monday, March 13th. She came in the following day for her second dose of Thyrogen. At this time, the nuclear medicine technologist was informed that the patient still had her thyroid. The technologist called the radiologist and asked how long the patient needed to be off of Thyrogen to have an I-123 scan. The technologist was told to call the radiopharmacy and ask. The technologist was also told to call the ordering provider to clarify the order. The technologist communicated with the ordering provider's nurse. The ordering provider did not know what to do at this point other than to continue with the study. No explanation was given to the ordering provider about the TBI scan or the effects of I-131 on their patient. The technologist proceeded with dosing the patient on March 15th with 4.4 mCi of I-131. The patient came back on Friday, March 17th for imaging. At this point, the radiologist realized that the technologist had performed the incorrect study and misadministered I-131. The health physicist was notified, and on Monday, March 20th, estimated that since no uptake was performed, that the patient received, at minimum, 14,000 rads/500 Rem to her thyroid gland from the dose of I-131." Arkansas Event Report ID No.: AR-2023-002 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 | |
|---|---|
| Baptist Health Medical Center Little Rock, Arkansas (NRC Region 4) | |
| License number: | ARK-0058-02120 |
| Organization: | Arkansas Department Of Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+176.95 h7.373 days <br />1.053 weeks <br />0.242 months <br />) | |
| Opened: | Susan Elliott 13:57 Mar 21, 2023 |
| NRC Officer: | Donald Norwood |
| Last Updated: | Mar 22, 2023 |
| 56423 - NRC Website | |
Baptist Health Medical Center with Agreement State | |
WEEKMONTHYEARENS 564232023-03-14T05:00:00014 March 2023 05:00:00
[Table view]Agreement State Medical Event 2023-03-14T05:00:00 | |