ENS Event | |
|---|---|
06:00 Jan 13, 2012 | |
| Title | Agreement State Report - Potential Medical Event |
| Event Description | A patient of Memorial Hermann in Houston received the wrong radioisotope. A dose of Gallium-67 was ordered, but a dose of Thallium-201 was delivered. Because the dose was improperly labeled as Gallium-67, the dose calibration process indicated an acceptable radioisotope and dose. The patient was injected with the wrong radioisotope on January 11, 2012. During patient imaging on January 13, 2012, it was realized that the patient received the wrong radioisotope. The pharmacy was notified of the error and admitted to delivery of the wrong isotope. The physicist at the hospital estimates that the patient received a dose of about 6 REM whole body.
Texas Incident Number: I-8921
The following information was received as an update: The licensee called to report that the wrong isotope was administered to a patient. Thallium 201 had been injected in a patient instead of Gallium 67 that was ordered. Apparently, the pharmacy sent the wrong isotope. 8 mCi of Gallium was ordered and a estimated 4.7 mCi of Thallium was delivered. Dose activities were similar and the dose calibrator didn't pick up the difference in isotope. Patient was injected on 1/11/12 and imaged 1/13/12. The mistake was discovered in imaging. The licensee will file a written report within 15 days. Notified R4DO (Pick) and FSME (McIntosh). 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. |
| Where | |
|---|---|
| Memorial Hermann Houston Houston, Texas (NRC Region 4) | |
| Organization: | Texas Department Of Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+12.45 h0.519 days <br />0.0741 weeks <br />0.0171 months <br />) | |
| Opened: | Bob Free 18:27 Jan 13, 2012 |
| NRC Officer: | Vince Klco |
| Last Updated: | Jan 17, 2012 |
| 47593 - NRC Website | |
Memorial Hermann Houston with Agreement State | |
WEEKMONTHYEARENS 475932012-01-13T06:00:00013 January 2012 06:00:00
[Table view]Agreement State Agreement State Report - Potential Medical Event 2012-01-13T06:00:00 | |