ENS Event | |
|---|---|
16:45 May 14, 2013 | |
| Title | Agreement State Report - Wrong Dose Administered to Patient |
| Event Description | 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
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. |
| Where | |
|---|---|
| St. Mary'S Regional Medical Center Reno, Nevada (NRC Region 4) | |
| License number: | 16-12-0244-02 |
| Organization: | Nv Div Of Rad Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+24.15 h1.006 days <br />0.144 weeks <br />0.0331 months <br />) | |
| Opened: | Sneha Ravikumar 16:54 May 15, 2013 |
| NRC Officer: | Pete Snyder |
| Last Updated: | May 16, 2013 |
| 49037 - NRC Website | |
St. Mary'S Regional Medical Center with Agreement State | |
WEEKMONTHYEARENS 490372013-05-14T16:45:00014 May 2013 16:45:00
[Table view]Agreement State Agreement State Report - Wrong Dose Administered to Patient 2013-05-14T16:45:00 | |