ENS 55882

v t e ENS Event
19:00 May 4, 2022
Title	Diagnostic Radiopharmaceutical Misadministration
Event Description	The following was received from the Utah Department of Environmental Quality (the Division) via email: At approximately 1030 MDT, the [Radiation Safety Officer] for the licensee notified the Division that a patient had been administered an isotope to perform a PET scan. The technician double checked with the ordering physician and found that the order was supposed to have been for a CT scan, not a PET scan. The order received showed it was a PET scan. An investigation is being conducted to see how the order was changed. The patient was administered about 10.6 mCi of FDG when a CT scan was to be performed. Therefore, the dose was greater than 20 percent of the prescribed dose. The order received by the radiology department showed that a PET scan had been ordered. The TEDE to the patient was less than 5 rem and the highest organ dose (to the bladder wall), was less than 50 rem. The patient was administered the FDG at about 1300 EDT on May 4, 2022. The FDG was allowed to decay and the patient was later given a CT exam. At this time, this is all the information that the Division has, an investigation will be conducted, and an update will be provided at a later date. Event Report ID No.: UT220004 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.

ENS 55882 +/-
Where
Central Utah Clinic, Revere Health Provo, Utah (NRC Region 4)
License number:	UT 2500361
Organization:	Utah Division Of Radiation Control
Reporting

Agreement State
Time - Person (Reporting Time:+20 h0.833 days <br />0.119 weeks <br />0.0274 months <br />)
Opened:	Gwyn Galloway 15:00 May 5, 2022
NRC Officer:	Lloyd Desotell
Last Updated:	May 5, 2022
55882 - NRC Website
v • d • e

v t e Emergency Notification System
Central Utah Clinic, Revere Health with Agreement State
WEEKMONTHYEAR2022-05-04T19:00:00 [Table view]
[ENS list for Central Utah Clinic, Revere Health]

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