ENS 44328

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v t e ENS Event
07:00 Jun 9, 2008
Title	Washington Agreement State Report - Potential Medical Event
Event Description	The following information was received from the State of Washington via email: On 9 June 2008 a patient presented for a prescribed bone scan (normally, Tc-99m, 30mCi, MDP), but instead received 23mCi of Tc-99m Sestamibi (heart scan). The dose was administered. No useful imaging or diagnostic information could be obtained from this procedure. The bone scan will be rescheduled. The licensee will submit a written report, containing cause and proposed corrective actions within 15 days. The licensee's written report dated 23 June 2008 indicates the cause to be human error by the nuclear medicine technologist. The licensee believes current procedures in place are adequate, providing staff adheres to those procedures. The technologist in question will now 'take a time out' prior to each injection to review the dose to be injected, the dose ordered, and to fully and thoroughly check the markings in place on syringes and vials to prevent such an occurrence. No media attention thus far. According to the manufacturer's product insert, the patient in this case could be expected to receive a maximum of: 4.14R to the Upper Large Intestinal Wall (the most for any single organ), and a whole body dose of 383 mR. No physical consequences are anticipated. Licensee notified patient and referring physician. * * UPDATE ON 06/30/2008 AT 1644 EST FROM FSME (ZELAC) TO ROTTON * * * The NRC has reviewed this event and determined it is not a reportable medical event.

ENS 44328 +/-
Where
St Mary Medical Center Walla Walla, Washington (NRC Region 4)
License number:	WN-M0101-1
Organization:	Wa Division Of Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+511.23 h21.301 days <br />3.043 weeks <br />0.7 months <br />)
Opened:	Arden Scroggs 14:14 Jun 30, 2008
NRC Officer:	Jeff Rotton
Last Updated:	Jun 30, 2008
44328 - NRC Website
v • d • e

v t e Emergency Notification System
St Mary Medical Center with Agreement State
WEEKMONTHYEAR2008-06-09T07:00:00 [Table view]
[ENS list for St Mary Medical Center]

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