ENS Event | |
|---|---|
07:00 Feb 28, 2024 | |
| Title | Medical Misadministration |
| Event Description | The following summary of information was provided by the Washington State Department of Health Office Radiation Protection (the Department) via email:
On March 1, 2024, the Department was notified of a medical misadministration that occurred on February 28, 2024. The misadministration was that of Ga-68 Dotatate (5.24 millicuries) being administered instead of F-18 FDG (Fludeoxyglucose). The licensee proceeded with the scan having an incomplete scan description on an outside physician's order. The signed order received only asked for "PET-CT Scan (Base of Skull to Thigh)." An unsigned order/history form, clearly designating a Ga-68 Dotatate scan, was filled out by the outside clinic's medical staff and included with the physician's order. The licensee proceeded with scan as directed using the elaboration of the unsigned order/history form as designation of the specific scan ordered. The patient was notified of the incident and will receive the appropriate scan the following week. Investigation in to how this situation can be avoided in the future has been conducted by the licensee. WA Event Number: WA-24-0007 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.
The following was provided by the Washington State Department of Health Office Radiation Protection (the Department) via email: The licensee provided a written report to the Department identifying root causes and corrective actions. The report also calculated an effective dose estimate of 498 mrem and the highest expected effective organ dose to the spleen of 5.47 rem. Notified R4DO (Werner) and NMSS Events (email) |
| Where | |
|---|---|
| Summit Cancer Center Spokane, Washington (NRC Region 4) | |
| License number: | WN-M0290 |
| Organization: | Wa Office Of Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+297.47 h12.395 days <br />1.771 weeks <br />0.407 months <br />) | |
| Opened: | Boris Tsenov 15:28 Mar 11, 2024 |
| NRC Officer: | Sam Colvard |
| Last Updated: | Mar 14, 2024 |
| 57023 - NRC Website | |
Summit Cancer Center with Agreement State | |
WEEKMONTHYEARENS 570232024-02-28T07:00:00028 February 2024 07:00:00
[Table view]Agreement State Medical Misadministration 2024-02-28T07:00:00 | |