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RE: "Oops!..I did it again."
"That's not what you said yesterday"
-----Original Message-----
From: William V Lipton [mailto:liptonw@DTEENERGY.COM]
Sent: Monday, September 10, 2001 2:19 PM
To: radsafe@list.vanderbilt.edu
Subject: "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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