When a York Hospital worker injected the wrong patient with radioactive blood cells on Dec. 27, the hospital had to take action quickly.
Required by state law to file a report of the incident within 24 hours, officials sent one to the state Department of Environmental Protection's Bureau of Radiation Protection on Dec. 28.
The report includes all the information they had at the time - which wasn't much, said WellSpan Health spokesman Barry Sparks.
The hospital's initial report stated that the drug, a radiopharmaceutical used to detect infections, was injected into the wrong patient, who experienced swelling at the injection site and no other adverse effects, he said.
The nuclear medicine technologist was immediately placed on administrative leave, according to the report.
Human error: After filing the report, the hospital dug deeper, Sparks said. People from various departments looked at what happened, why and what they could do to prevent it from happening again, he said.
At York Hospital, workers must check patients' ID bracelets and ask for a name and date of birth, Sparks said. When administering radiopharmaceuticals, there is an additional bracelet that workers must check, he said.
The technologist did not check the patient's bracelet nor correlate the name and birthdate provided verbally from the wrong patient, the report says.
"This is just human error," Sparks said.
The hospital also found that the dose of the drug was smaller than initially reported, with radiation levels equal to what an average person would receive from the natural environment in a year's time, he said.
"Based on more information, the dosage was actually below reportable levels," Sparks said.
Second report: The hospital Friday released a final report, which reflects the recalculated dosage of the drug, he said.
"We fully expect that the initial report will be retracted," he said.
Sparks wants to remind patients that York Hospital's staff works hard to assure their safety.
"WellSpan is committed to offering exceptional patient care every day," he said.
DEP continues to investigate the case.
- Reach Mollie Durkin at firstname.lastname@example.org.