ENS 45291

v t e ENS Event
05:00 Jul 9, 2009
Title	Agreement State Report - Medical Event Involving Radiopharmaceuticals
Event Description	The following report was received from the State of Louisiana via facsimile: On July 9, 2009, a facility reported a mislabeled unit dose from GE Healthcare nuclear pharmacy. Three 20 mCi unit doses of Tc-99m MDP (bone scans) were ordered by Ochsner [a medical facility]. Two patients were injected. After viewing the images, it was determined that the unit doses were mislabeled. An investigation of GE Healthcare was performed. A preliminary cause was determined to be a mix up of MDP cold vial with DTPA [renal scans] as they closely resemble each other with the same vial configuration and same color label. Contributing factors leading to the incident were Tc-99m/Mo-99 shortage, late arrival of generators, increased number of kits to prepare as a result of the shortage, and pharmacist working alone. Corrective actions involved reviewing procedures and discontinuing manual changes of inventory dispensed on prescription labels. Louisiana incident number: LA090017 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 45291 +/-
Where
Ge Healthcare New Orleans, Louisiana (NRC Region 4)
License number:	LA-5470-L01
Organization:	Louisiana Deq
Reporting

Agreement State
Time - Person (Reporting Time:+1133.95 h47.248 days <br />6.75 weeks <br />1.553 months <br />)
Opened:	Ann Troxler 10:57 Aug 25, 2009
NRC Officer:	Dong Park
Last Updated:	Aug 25, 2009
45291 - NRC Website
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v t e Emergency Notification System
Ge Healthcare with Agreement State
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