ENS 53728

v t e ENS Event
05:00 Nov 9, 2018
Title	Patient Underdosage Due to Loss of Air Seal Integrity
Event Description	Today, Nov 9, 2018 a medical event occurred at our facility in which 145.7 mCi of Lutathera Lutetium-177 was delivered out of the prescribed 200 mCi. The full dose could not be delivered as there was loss of integrity of the air seal on the Lutathera vial. The licensee indicated the cause of the event was still under investigation and the Doctor and patient were informed of the issue. The licensee has not notified the Region III office. 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.

ENS 53728 +/-
Where
Gershenson Radiation Oncology Center Detroit, Michigan (NRC Region 3)
License number:	21-04127-06
Organization:	Karmanos Cancer Center
Reporting

10 CFR 35.3045(a)(1)
Time - Person (Reporting Time:+11.35 h0.473 days <br />0.0676 weeks <br />0.0155 months <br />)
Opened:	Joe Rakowski 16:21 Nov 9, 2018
NRC Officer:	Jeff Herrera
Last Updated:	Nov 9, 2018
53728 - NRC Website
v • d • e

v t e Emergency Notification System
Gershenson Radiation Oncology Center with 10 CFR 35.3045(a)(1)
WEEKMONTHYEAR2018-11-09T05:00:00 [Table view]
[ENS list for Gershenson Radiation Oncology Center]

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