ENS Event | |
|---|---|
05:00 Apr 6, 2005 | |
| Title | Medical Event Involving Administration Of Wrong Diagnostic Test |
| Event Description | On the morning of 4/6, the Resident Physician reviewed the prescribing Physician's order for administration of a brain scan diagnostic test to image a tumor and instructed the technician to perform a "standard" brain scan which images blood flow. The Technician administered 30 mCi Tc-99m as instructed rather than the 3 mCi Thallium prescribed. The RSO noted that the test performed would result in a total dose of 3.22 mGy and a urinary bladder wall dose of 81 mGy (information from package insert). The RSO does not believe there will be any adverse consequences to the patient in that this was a diagnostic test. The error was identified by the Director of Nuclear Medicine during review. The patient had not been informed as of the time of this report. The patient will be rescheduled for the appropriate diagnostic test after elimination and decay of the Tc-99m.
The license stated that the patient involved was a 66 year old female. The licensee does not consider that this event meets the criteria of a medical event. R1DO (Noggle) and NMSS (Essig) notified. |
| Where | |
|---|---|
| University Of Virginia Charlottesville, Virginia (NRC Region 1) | |
| License number: | 45-00034-26 |
| Organization: | University Of Virginia |
| Reporting | |
| 10 CFR 35.3045(a)(2) | |
| Time - Person (Reporting Time:+11.98 h0.499 days <br />0.0713 weeks <br />0.0164 months <br />) | |
| Opened: | Ralph Allen 16:59 Apr 6, 2005 |
| NRC Officer: | Steve Sandin |
| Last Updated: | Apr 7, 2005 |
| 41572 - NRC Website
Loading map... {"minzoom":false,"maxzoom":false,"mappingservice":"leaflet","width":"350px","height":"250px","centre":false,"title":"","label":"","icon":"","lines":[],"polygons":[],"circles":[],"rectangles":[],"copycoords":false,"static":false,"zoom":6,"defzoom":14,"layers":["OpenStreetMap"],"image layers":[],"overlays":[],"resizable":false,"fullscreen":false,"scrollwheelzoom":true,"cluster":false,"clustermaxzoom":20,"clusterzoomonclick":true,"clustermaxradius":80,"clusterspiderfy":true,"geojson":"","clicktarget":"","imageLayers":[],"locations":[{"text":"\u003Cb\u003E\u003Cdiv class=\"mw-parser-output\"\u003E\u003Cp\u003E\u003Ca class=\"mw-selflink selflink\"\u003EENS 41572\u003C/a\u003E - \u003Ca href=\"/University_of_Virginia\" title=\"University of Virginia\"\u003EUniversity of Virginia\u003C/a\u003E\n\u003C/p\u003E\u003C/div\u003E\u003C/b\u003E\u003Cdiv class=\"mw-parser-output\"\u003E\u003Cp\u003EMedical Event Involving Administration of Wrong Diagnostic Test\n\u003C/p\u003E\u003C/div\u003E","title":"ENS 41572 - University of Virginia\n","link":"","lat":38.033369444444446,"lon":-78.50944722222222,"icon":""}],"imageoverlays":null} | |
University of Virginia with 10 CFR 35.3045(a)(2) | |
WEEKMONTHYEARENS 415722005-04-06T05:00:0006 April 2005 05:00:00
[Table view]10 CFR 35.3045(a)(2) Medical Event Involving Administration of Wrong Diagnostic Test 2005-04-06T05:00:00 | |