Event Notification Report for June 26, 2023

AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION

The following information was provided by the Oklahoma Department of Environmental Quality (DEQ) via email:

"On June 26, 2023, a referring physician ordered 300 microcuries for an I-123 thyroid and uptake scan. Instead, outpatient scheduling ordered a 21.1 millicuries Tc-99m sestamibi parathyroid exam. Neither the registration nor the nuclear medicine department reviewed the physician's order, and the Tc-99m sestamibi was administered. Using the nuclear medicine dose tool, the radiation dose estimates provided by the licensee for the I-123 uptake and scan would have been an approximate effective dose equivalent of 0.24 rem with the thyroid being the critical organ receiving 5.20 rad. Using the nuclear medicine dose tool, the radiation dose estimates provided by the licensee for the Tc-99m sestamibi parathyroid exam was an approximate effective dose equivalent of 0.62 rem with the gallbladder being the critical organ receiving 3.83 rad.

"In his email, the radiation safety officer stated that their local steps after this incident will be: to have in-depth conversations with techs and outpatient scheduling manager; initiate an incident report (internal and misadministration form); make notifications to the patient and attending physician; and engage the risk management and internal sentinel event process. The incident will be documented and reviewed in the July radiation safety meeting. It will also be reviewed during the daily facility safety meeting with C-Suites and all facility directors/managers.

"Additional updates will be made as they are received according to SA-300."

DEQ Event #1278

* * * RETRACTION ON 07/05/23 AT 1022 EDT FROM JULIA ROBERTS TO KERBY SCALES * * *

The following is a summary of information provided by DEQ via email:

The event was not a reportable medical event due to not meeting the threshold for reporting under 10 CR 35.3045(a)(1)(ii)(A).

Notified R4DO (Drake) and NMSS Events Notification (email).

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.

AGREEMENT STATE REPORT - STOLEN GAUGE

The following information was provided by the Maryland Department of the Environment via telephone:

On 6/26/23 at 1116 EDT, the licensee was working at Howard University in Washington, D.C. when a Niton XLp 300 (lead base paint analyzer containing a maximum of 50 mCi of Cd-109) was stolen out of a vehicle. The Howard University and Washington, D.C. police were notified of the vehicle break in.

THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf