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"Oops!..I did it again."



With my apologies to Britney Spears:



The opinions expressed are strictly mine (and Britney's)

It's not about dose, it's about trust.



Bill Lipton

liptonw@dteenergy.com



REP ORG:  MADISION MEMORIAL HOSPITAL           |NOTIFICATION DATE:

09/07/2001|

|LICENSEE:  MADISON MEMORIAL HOSPITAL            |NOTIFICATION TIME:

18:03[EDT]|

|    CITY:  REXBURG                  REGION:  4  |EVENT DATE:

09/06/2001|

|  COUNTY:                            STATE:  ID |EVENT TIME:

13:30[MDT]|

|LICENSE#:  1127358-01            AGREEMENT:  N  |LAST UPDATE DATE:

09/07/2001|

|  DOCKET:

|+----------------------------+

|                                                |PERSON

ORGANIZATION |

|                                                |LINDA SMITH

R4      |

|                                                |M. WAYNE HODGES

NMSS    |

+------------------------------------------------+

|

| NRC NOTIFIED BY:  J. WALKER

|                             |

|  HQ OPS OFFICER:  JOHN MacKINNON

|                             |

+------------------------------------------------+

|

|EMERGENCY CLASS:          NON EMERGENCY

|                             |

|10 CFR SECTION:

|                             |

|LADM 35.33(a)            MED MISADMINISTRATION

|                             |

|

|                             |

|

|                             |

|

|                             |

|

|                             |

+------------------------------------------------------------------------------+



                                   EVENT TEXT

+------------------------------------------------------------------------------+



| PATIENT GIVEN TECHNETIUM-99 MDP INSTEAD OF

MYOVIEW.                          |

|

|

| Nuclear Medicine Technologist placed a vial that he thought

contained        |

| technetium-99 myoview into a carrier and took it across the hallway.

He     |

| administered 32.2 millicuries of technetium-99 MDP instead of

32.2           |

| millicuries of technetium-99 myoview to a patient walking on a tread

mill.   |

| The nuclear Medicine Technologist discovered that the patient received

the   |

| incorrect technetium while imaging the patient.  The Nuclear

Medicine        |

| technologist notified the radiologist of the error but has not

contacted the |

| patient or the patients physician. The patient's physician left for

the      |

| weekend after the technetium-99 myoview had been administered to

the         |

| patient.   No harm to the patient due to incorrect technetium given to

the   |

|

patient.

|

+------------------------------------------------------------------------------+









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