[19982596]
In the pet scan procedure room quality control procedure are performed daily prior to patient infusions. Three qc tasks are completed - the wash, calibration, and level testing to test for the concentration of the undesirable isotopes, sr-82 and sr-85. A bag of saline solution is used to accomplish the qc tests. On the morning of (b)(6) 2015 these testing procedures were done and found to be satisfactory. The saline bag was replaced after the testing was performed as a matter of routine occurrence. The 500 ml ns bag was inadvertently replaced with a 500 ml bag of lactated ringers. Lactated ringer's solution should not be used with the rb-82 generator because it will result in the release of significantly more sr-82/85 in the elution. There were five patients who received pet scans on (b)(6) 2015 with lactated ringers. On the following day, (b)(6) 2015, a nuclear medicine technologist performed the wash, level and calibration test. The wash and level tests were found to be acceptable. The calibration test was completed and a small deviation from the expected reading was noted. The test was repeated with equivalent results. This test indicated lower than expected volume to produce the same activity. Shortly thereafter it was noticed that the bag hanging on the generator to complete the qc tests did not contain the saline solution and was lactated ringer's solution. Bracco diagnostics, inc. Was called. Patient infusions were cancelled for the day. Patient was called back to hospital on (b)(6) 2015 for radiation survey using a model 14c gm survey meter with no activity above background level detected. Net dose rate was zero. Also see mw5043403, mw5043406.
Patient Sequence No: 1, Text Type: D, B5