ENS Event | |
|---|---|
04:00 Aug 3, 2009 | |
| Title | Agreement State Report - Late Reporting for Diagnostic Misadministration |
| Event Description | The following information was provided by the State of Georgia via email:
Licensee contacted the Department [Georgia Radioactive Materials Program] via telephone on 8/12/09 reporting that a patient who underwent a nuclear cardiology treadmill stress test on 8/3/09 resulted in an embryo/fetus exposure greater than 500 mRem. The Department received a report from the licensee on 8/14/12 describing that prior to treatment the patient declared to the licensee that she was not pregnant and the licensee followed in house protocols in which all female patients under the age of 55 are asked if they are currently pregnant or breastfeeding. In the event that a patient is unsure the licensee postpones testing until a negative pregnancy test can be obtained. The patient later informed the licensee of her pregnancy on 8/10/09. Isotopes and activity administered to the patient were as follows: Tc-99m 28.2 mCi & Tl-201 3.62 mCi with a Total Activity of 31.82 mCi. RSO for the licensee & consulting medical physicists conducted a dose determination and the conclusion was that the embryo/fetus did receive an effective dose equivalent in excess of 500 mRem. The results were forwarded to the patient's OBGYN. This was a diagnostic misadministration that did not involve contamination.
The following information was excerpted from a received facsimile: [The update is concerned with] the radiopharmaceutical dose administration that a female patient recently received at the testing facilities. It was subsequently determined that this patient was 4 months pregnant. The patient received two dose administrations, one dose of Tc-99m - Myoview for the Stress Myocardial Perfusion scan and one dose of Tl-201 as Thallous Chloride for the Rest Myocardial Perfusion scan. The patient received 28.2 mCi of Tc-99m-Myoview and 3.62 mCi of TI-201. The dose to the conceptus was approximately 1.97 Rad. Determination of dose is limited by patient habitus and physiology. Notified the R1DO (Bellamy) and FSME Resources. Report: GA-2009-12i NMED# 090811 |
| Where | |
|---|---|
| Atlanta Heart Associates, P.C. Atlanta, Georgia (NRC Region 1) | |
| License number: | Ga 1271-1 |
| Organization: | Georgia Radioactive Material Pgm |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+28474.93 h1,186.455 days <br />169.494 weeks <br />39.005 months <br />) | |
| Opened: | Travis Cartoski 14:56 Nov 1, 2012 |
| NRC Officer: | John Knoke |
| Last Updated: | Jan 30, 2013 |
| 48469 - NRC Website | |
Atlanta Heart Associates, P.C. with Agreement State | |
WEEKMONTHYEARENS 550722021-01-04T05:00:0004 January 2021 05:00:00
[Table view]Agreement State Leaking Calibration Source ENS 484702009-08-17T04:00:00017 August 2009 04:00:00 Agreement State Agreement State Report - Late Reporting for Diagnostic Misadministration ENS 484692009-08-03T04:00:0003 August 2009 04:00:00 Agreement State Agreement State Report - Late Reporting for Diagnostic Misadministration 2021-01-04T05:00:00 | |