ENS Event | |
|---|---|
07:00 Sep 11, 2008 | |
| Title | Greater than Prescribed Dose Adminstered to Patient |
| Event Description | On Wednesday, September 17, 2008, [a Certified Nuclear Medical Technologist] at Universal Health Services of Rancho Springs, Inc., contacted RHB about a diagnostic misadministration, which had occurred on September 11, 2008. The patient was prescribed a 7 milliCurie dose of Tc-99m Hebrofenin for a Hepatobiliary study (HIDA). At approximately 2:10 P.M. on September 11, 2008, the patient was given a dose of 22 milliCuries of Tc-99m Sestamibi, used for cardiac studies. The dose given was 50% greater than the intended dose. No additional Tc-99m was given since the image required was obtained with the dose that was actually given. The technician had grabbed the wrong syringe from the dose cart. The reason given for the misadministration was a heavy workload. The corrective actions to be taken to prevent a recurrence were to implement new procedures for radiopharmaceutical labeling and handling and to reinstruct personnel. Since the dose administered to the patient was 50% greater than the prescribed dose, the reportability of this event is 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />. This event will be investigated by RHB South.
California Report #5010-091708 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 report was received via e-mail: The state of California is retracting this event. "After additional review, we determined that it was not actually a reportable event. The dose the individual received did not meet the threshold necessary to be reportable under 10CFR35.3045 - Medical Event. Notified the R4DO (Pick) and FSME (Einberg). |
| Where | |
|---|---|
| Universal Health Svc. Of Rancho Springs, Inc. Wildomar, California (NRC Region 4) | |
| License number: | 2811-33 |
| Organization: | California Radiation Control Prgm |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+154.65 h6.444 days <br />0.921 weeks <br />0.212 months <br />) | |
| Opened: | Delia Aquino 17:39 Sep 17, 2008 |
| NRC Officer: | Dan Livermore |
| Last Updated: | Sep 18, 2008 |
| 44500 - NRC Website | |
Universal Health Svc. Of Rancho Springs, Inc. with Agreement State | |
WEEKMONTHYEARENS 445002008-09-11T07:00:00011 September 2008 07:00:00
[Table view]Agreement State Greater than Prescribed Dose Adminstered to Patient 2008-09-11T07:00:00 | |