Event Notification Report for August 25, 2022
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
08/24/2022 - 08/25/2022
EVENT NUMBERS
56071
56071
Agreement State
Event Number: 56071
Rep Org: Alabama Radiation Control
Licensee: Huntsville Hospital Health System
Region: 1
City: Huntsville State: AL
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Cason Coan
HQ OPS Officer: Bethany Cecere
Licensee: Huntsville Hospital Health System
Region: 1
City: Huntsville State: AL
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Cason Coan
HQ OPS Officer: Bethany Cecere
Notification Date: 08/26/2022
Notification Time: 16:13 [ET]
Event Date: 08/25/2022
Event Time: 00:00 [CDT]
Last Update Date: 09/02/2022
Notification Time: 16:13 [ET]
Event Date: 08/25/2022
Event Time: 00:00 [CDT]
Last Update Date: 09/02/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Lally, Christopher (R1DO)
Williams, Kevin (NMSS)
NMSS_Events_Notification, (EMAIL)
Lally, Christopher (R1DO)
Williams, Kevin (NMSS)
NMSS_Events_Notification, (EMAIL)
EN Revision Imported Date: 9/6/2022
EN Revision Text: AGREEMENT STATE REPORT - DIAGNOSTIC MISADMINISTRATION
The following information was provided by the Alabama Dept. of Public Health Office of Radiation Control via email:
"[The licensee's] Representative stated that a patient was prescribed 20 milliCuries of sodium pertechnetate (did not state for which type of scan); the patient received 30 milliCuries of sestamibi (intended for a cardiac stress dose). The representative stated that the nuclear medicine tech that administered the wrong dose is new and has been counseled. This nuclear medicine tech will also be subject to increased oversight into the near future. Representative did not state that the patient will experience any side effects, nor if the patient has been counseled. The misadministration appears to result in an EDE of 876.9 mrem; the highest organ/tissue dose appears to be to the gall bladder wall with a dose of estimated 3663 mrem."
Alabama Incident 22-14
* * * UPDATE ON 9/01/2022 AT 1634 EDT FROM ALABAMA OFFICE OF RADIATION CONTROL TO KAREN COTTON * * *
"Cause and Corrective Actions (State's and licensees' actions):
"The tech that administered the wrong dose was still in her orientation/training period. The licensee stated that the tech was counseled and will be under increased monitoring during her orientation period.
"Close-out report"
Notified NMSS DAY (Rivera-Cappella) and R1DO (Gray) and via email: NMSS Event Notification
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.
EN Revision Text: AGREEMENT STATE REPORT - DIAGNOSTIC MISADMINISTRATION
The following information was provided by the Alabama Dept. of Public Health Office of Radiation Control via email:
"[The licensee's] Representative stated that a patient was prescribed 20 milliCuries of sodium pertechnetate (did not state for which type of scan); the patient received 30 milliCuries of sestamibi (intended for a cardiac stress dose). The representative stated that the nuclear medicine tech that administered the wrong dose is new and has been counseled. This nuclear medicine tech will also be subject to increased oversight into the near future. Representative did not state that the patient will experience any side effects, nor if the patient has been counseled. The misadministration appears to result in an EDE of 876.9 mrem; the highest organ/tissue dose appears to be to the gall bladder wall with a dose of estimated 3663 mrem."
Alabama Incident 22-14
* * * UPDATE ON 9/01/2022 AT 1634 EDT FROM ALABAMA OFFICE OF RADIATION CONTROL TO KAREN COTTON * * *
"Cause and Corrective Actions (State's and licensees' actions):
"The tech that administered the wrong dose was still in her orientation/training period. The licensee stated that the tech was counseled and will be under increased monitoring during her orientation period.
"Close-out report"
Notified NMSS DAY (Rivera-Cappella) and R1DO (Gray) and via email: NMSS Event Notification
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.