ENS Event | |
|---|---|
05:00 Sep 21, 2018 | |
| Title | Possible Extravasation of Ra-223 |
| Event Description | The patient's first dose of 110.3 microCuries, 4.3 mL, of Ra-223 (Xofigo) was administered today, 9/21/18 at 1040 CDT. An IV was placed by RN [Registered Nurse] in the patient's left wrist. The IV was flushed with saline and blood return was checked and present prior to administration of Ra-223 by [the] MD [medical doctor]. The Ra-223 was delivered by MD. After delivery, the MD began [a] saline flush and after approximately 5cc of saline, noted resistance and a cold bulge near the infusion site. He was not able to get blood return. The RN was called in to check the IV and was not able to get blood return. It was noted an infiltration/extravasation had occurred. The IV was removed with catheter noted to be intact. Prior to the infusion the patient was told that the infusion should not be painful and he did not acknowledge any pain or discomfort during or after infusion. At this time it is not known if there was an extravasation of Ra-223 because the infiltration/extravasation was not noted until during the second saline flush. The patient and patient's family were notified at the time of the incident.
The licensee does not believe there was more than 10 percent of therapy dose that was not infiltrated. Based on the fact that the swelling went down in less than 45 minutes post imaging of the wrist, compared to the body, leads the Radiation Safety Officer (RSO) to believe most of the therapy dose went throughout the body. Notified R3DO (Orth) and NMSS vis email. 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. |
| Where | |
|---|---|
| Missouri Baptist Medical Center Rso, Missouri (NRC Region 3) | |
| License number: | 24-11128-02 |
| Organization: | Missouri Baptist Medical Center |
| Reporting | |
| 10 CFR 35.3045(a)(3) | |
| Time - Person (Reporting Time:+12.67 h0.528 days <br />0.0754 weeks <br />0.0174 months <br />) | |
| Opened: | Amy Ettling 17:40 Sep 21, 2018 |
| NRC Officer: | Jeff Herrera |
| Last Updated: | Oct 3, 2018 |
| 53616 - NRC Website | |
Missouri Baptist Medical Center with 10 CFR 35.3045(a)(3) | |
WEEKMONTHYEARENS 536162018-09-21T05:00:00021 September 2018 05:00:00
[Table view]10 CFR 35.3045(a)(3) Possible Extravasation of Ra-223 ENS 406962004-03-01T05:00:0001 March 2004 05:00:00 10 CFR 35.3045(a)(3) Dose to the Skin Other than the Intended Treatment Site 2018-09-21T05:00:00 | |