The following information was obtained from the State of Nevada via email:
The patient was to undergo a HIDA [hepatobiliary] scan for abdominal pain (Tc-99m; 5mCi, abdomen), but given syringe for MDP [bone scan] (Tc-99m; 30mCi; bone). A wrong dose of Tc-99m (600% the prescribed dose) was administered to the patient due to human error.
Corrective action: Better training in cross-checking and confirming patient identity with prescribed dose information.
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.
Item Number: NV130006
- * * RETRACTION FROM SNEHA RAVIKUMAR VIA E-MAIL ON 5/16/13 AT 1329 EDT * * *
This is with regard to the wrong dose administration that was reported yesterday. [The State of Nevada] heard back from the RSO regarding the Effective Dose Equivalent:
What should have been administered was 5 mCi of HIDA (Mebrofenin) = (3E-02) x 5 rem = 0.15 rem.
What was administered was 30 mCi of MDP = (2E-02) x 30 rem = 0.60 rem.
So, this would not be reportable.
Notified R4DO (Walker) and
FSME Events Resource via E-mail.