ENS Event | |
|---|---|
14:00 Apr 22, 2009 | |
| Title | Agreement State - Medical Misadministration |
| Event Description | The following was received from the agreement state with a state control number of KY0901:
At 1400 on 4/22/2009, the RSO of a medical licensee reported the misadministration of a radiopharmaceutical to a seven-month-old infant. The infant was scheduled for a renal scan and was ordered to receive a 2 mCi dose tagged with Tc-99m. The patient was inadvertently administered a 35 mCi dose of Sestamibi/Tc-99M. Event date: 4/22/2009. Discovery date: 4/22/2009. Report date: 4/22/2009. Licensee Reporting Party Information: University of Kentucky, Lexington KY 40506, License number: 202-049-22. Site of event: Lexington, KY. Event type: MD2 - Medical event. Event cause: Human error. The patient was informed on 4/22/2009. The intended diagnostic study was renal-glomerular filtration with dimercaptosuccinic acid (DMSA) radiopharmaceutical, with a 2 mCi (74 MBq) Tc-99m radionuclide. The given diagnostic study was cardiac perfusion with sestamibi/cardiolite radiopharmaceutical, with a 34.9 mCi (1291.3 MBq) Tc-99m radionuclide. The dose exceeded the prescribed dose by 1650%. It is estimated that the heart received a dose of 2.84 rem, and the whole body does was 6.84 rem. The effect on the patient is unknown at this time. 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 | |
|---|---|
| University Of Kentucky Lexington, Kentucky (NRC Region 1) | |
| License number: | 202-049-22 |
| Organization: | Kentucky Dept Of Radiation Control |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+21.77 h0.907 days <br />0.13 weeks <br />0.0298 months <br />) | |
| Opened: | Michele Greenwell 11:46 Apr 23, 2009 |
| NRC Officer: | Karl Diederich |
| Last Updated: | Apr 23, 2009 |
| 45011 - NRC Website | |
University Of Kentucky with Agreement State | |
WEEKMONTHYEARENS 568162023-10-23T05:00:00023 October 2023 05:00:00
[Table view]Agreement State Possible Dose Misadministration ENS 567652023-09-28T14:30:00028 September 2023 14:30:00 Agreement State Possible Misadministration ENS 457162010-02-23T15:45:00023 February 2010 15:45:00 Agreement State Agreement State Report - Gamma Knife Treatment to Wrong Location ENS 450112009-04-22T14:00:00022 April 2009 14:00:00 Agreement State Agreement State - Medical Misadministration ENS 411612004-10-22T19:00:00022 October 2004 19:00:00 Agreement State Agreement State Report ENS 400562003-06-23T20:30:00023 June 2003 20:30:00 Agreement State Agreement State Report 2023-09-28T14:30:00 | |