Event Notification Report for May 28, 2023
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
05/27/2023 - 05/28/2023
EVENT NUMBERS
56546
56546
Agreement State
Event Number: 56546
Rep Org: Florida Bureau of Radiation Control
Licensee: Santa Rosa Medical Center
Region: 1
City: Milton State: FL
County:
License #: 3356-1
Agreement: Y
Docket:
NRC Notified By: Ashley Pierre-Saint
HQ OPS Officer: Adam Koziol
Licensee: Santa Rosa Medical Center
Region: 1
City: Milton State: FL
County:
License #: 3356-1
Agreement: Y
Docket:
NRC Notified By: Ashley Pierre-Saint
HQ OPS Officer: Adam Koziol
Notification Date: 05/31/2023
Notification Time: 11:22 [ET]
Event Date: 05/28/2023
Event Time: 00:00 [EDT]
Last Update Date: 06/01/2023
Notification Time: 11:22 [ET]
Event Date: 05/28/2023
Event Time: 00:00 [EDT]
Last Update Date: 06/01/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Cahill, Christopher (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Rivera-Capella, Gretchen (NMSS DAY)
Cahill, Christopher (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Rivera-Capella, Gretchen (NMSS DAY)
AGREEMENT STATE REPORT - MEDICAL EVENT - INCORRECT TARGET ORGAN
The following information was provided by the Florida Department of Health Bureau of Radiation Control (BRC) via email:
"The Radiation Safety Officer (RSO) for Santa Rosa Medical Center, called the BRC to report an incident which occurred on Sunday 5/28/23. A technician was performing a lung scan on a patient and accidentally grabbed the wrong dose. The patient received 4 mCi of Tc-99 before the technician realized her mistake; whole dose would have been 10 mCi. The radiologist and the patient were both made aware of the incident.
"Licensing and technology is being asked to further investigate this incident."
The following additional information was obtained from the RSO:
The prescribed dose was 10 mCi of Tc-99 tagged for lung scan while the administered dose of Tc-99 was tagged for the liver. The total body effective dose equivalent to the patient was 80 mrem.
Florida Incident Number: FL23-082
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.
The following information was provided by the Florida Department of Health Bureau of Radiation Control (BRC) via email:
"The Radiation Safety Officer (RSO) for Santa Rosa Medical Center, called the BRC to report an incident which occurred on Sunday 5/28/23. A technician was performing a lung scan on a patient and accidentally grabbed the wrong dose. The patient received 4 mCi of Tc-99 before the technician realized her mistake; whole dose would have been 10 mCi. The radiologist and the patient were both made aware of the incident.
"Licensing and technology is being asked to further investigate this incident."
The following additional information was obtained from the RSO:
The prescribed dose was 10 mCi of Tc-99 tagged for lung scan while the administered dose of Tc-99 was tagged for the liver. The total body effective dose equivalent to the patient was 80 mrem.
Florida Incident Number: FL23-082
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.