ENS Event | |
|---|---|
19:00 Jul 21, 2010 | |
| Title | Agreement State Report - Potential Medical Event |
| Event Description | Narrative: On 7/21/2010 at 12:00 p.m at the Hot Lab: 17 yr old patient came in for MIRALUMA study. STD dose is 25 mCi of Tc-99m MIRALUMA. Based on patient weight, (105 lbs), pediatric dose is calculated at 17.5 mCi. IV was started by mammography technician. Nuclear medicine technician went to physician to notify about pediatric dose. At this time, mammography technician assayed dose at 24.0 mCi and injected patient.
Reported to the Nevada Radiation Control Program at around 3:00 p.m. The event is NRC reportable under 10CFR35.3045, since it is a dose different from the prescribed dose. Since 10 CFR 35 has been adopted by the state, it is reportable under state requirements too. Persons involved: Pediatric patient, mammography technician and nuclear medicine technician. Corrective Actions: Communication and cross-checking correct dosing especially during pediatric procedures. Root causes and contributing factors: Haste and the mammography technician not recognizing the fact that the patient was a pediatric patient. Isotope Details: Tc-99m: 24.0 mCi. Procedure administered: MIRALUMA study. Dose intended: 17.5 mCi of Tc-99m Dose Administered: 24.0 mCi of Tc-99m Target organ: Breast Patient Informed: N % Dose Exceeds Prescribed: 37 Diagnostic Study: Breast (MIRALUMA study) Radiopharmaceutical: Tc-99m MIRALUMA Effect on Patient: UNKNOWN Source/Radioactive Material: UNSEALED SOURCE RADIOPHARM Manufacturer: Cardinal Health PSC Model Number: 190 Nevada Report No.: NV100011 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 | |
|---|---|
| West Valley Imaging Henderson, Nevada (NRC Region 4) | |
| License number: | 03-12-0384-01 |
| Organization: | Nv Div Of Rad Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+18.5 h0.771 days <br />0.11 weeks <br />0.0253 months <br />) | |
| Opened: | Sneha Ravikumar 13:30 Jul 22, 2010 |
| NRC Officer: | Steve Sandin |
| Last Updated: | Jul 22, 2010 |
| 46117 - NRC Website | |
West Valley Imaging with Agreement State | |
WEEKMONTHYEARENS 461172010-07-21T19:00:00021 July 2010 19:00:00
[Table view]Agreement State Agreement State Report - Potential Medical Event 2010-07-21T19:00:00 | |