Interference of Residual 99m Tc-MIBI Activity in Syringe Needle on 99m Tc-DMSA Scan Interpretation; Medical Error.

Abstract

A 4-month-old infant with a small right kidney underwent a 99m Tc-DMSA scan showing unjustifiable findings including global cortical loss in the left kidney, increased liver and bowel uptake. Retrospective review revealed reuse of a sterile needle contaminated with residual 99m Tc-MIBI, compromising scan quality and falsely elevating right kidney function. A repeat scan showed normal left kidney uptake and significantly reduced right kidney function. This case highlights the importance of employing safe techniques with disposable equipment, thorough workflow review, and transparent error reporting in nuclear medicine to ensure accurate diagnosis and patient safety.