The following report was received via e-mail:
A patient was treated in the nuclear medicine department on October 6, 2009 with Quadramet (Sm-153 EDTMP) for bone pain administered by the user. The Nuclear Pharmacy prepared, assayed and dispensed 43.5 mCi of Quadramet. The dose was prepared with a needle attached to a syringe. After administration, the syringe and additional materials were returned to the Nuclear Pharmacy for re-assay to determine the activity remaining in the administering materials. Reassaying is a standard procedure. The assay revealed that 12.7 mCi of the Sm-153 remained in the syringe cap and the needle itself. The administered dose was determined to be 30.8 mCi, an underdose of approximately 30%.
[The] attending physician in consultation with the Authorized User agreed not to bring the patient back to add to the dose already administered and to await the result of response. In their opinion, there will be no adverse affect on the patient.
The Nuclear pharmacy will review whether a needle needs to be present on the dose syringe when dispensed. Nuclear pharmacy will also investigate availability and use of three-way lock to facilitate flushing of the syringe.
An update will be provided when an investigation is done by an inspector from the New York City Office of Radiological Health.
- * * UPDATE FROM LICKERMAN TO KLCO ON 9/23/11 AT 1437 EDT* * *
The department inspector investigated the above medical event and determined information to be consistent with the initial report to NRC shown above. In addition, the inspector determined that the licensee has instituted corrective actions which should prevent an occurrence of this type of event in the future. In particular:
-The nuclear pharmacy will dispense and calibrate syringe with a cap but without a needle attached;
-Three-way stopcocks will be distributed as standard instruments with all Sm-153 doses to facilitate flushing of the syringe;
-In annual training/retraining, it will be emphasized that Authorized Users must return syringe setups to the nuclear pharmacy for clarification if any setup is incorrect or appears to differ from that which is required per procedure.
No violations were issued following the field inspection.
Notified the R1DO (Newport) and FSME (O'Sullivan).
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.