ENS 54514

v t e ENS Event
06:00 Feb 2, 2020
Title	Agreement State Report - Medical Event
Event Description	The following was received from the state of Minnesota via email: Lu-177 administration was performed on February 4, 2020. The administration team did not start the patient on amino acids prior to the administration. Upon discovery of the error, the acids were started. This resulted in an unintended dose to the kidneys. The Radiation Safety Officer (RSO) and staff were notified on February 5, 2020. They determined it was a medical event on February 7, 2020 at 0930 CST. The event was reported to the Minnesota Department of Health (MDH) at 1000 CST on February 7, 2020. The intended dose to the kidney was 490 Rem. The delivered dose to the kidney was 740 Rem (this was their 'best case scenario' calculation). This would fall under 4731.4525 Subpart 1 Item C.: 'a dose to the skin or an organ or tissue other than the treatment site that exceeds 50 Rem and exceeds 50 percent of the dose expected from the administration defined in the written directive.' This event is still under investigation with MDH. Minnesota Event Report ID: MN200002 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 54514 +/-
Where
Minnesota Department Of Health Rochester, Minnesota (NRC Region 3)
License number:	1047
Organization:	Minnesota Department Of Health
Reporting

Agreement State
Time - Person (Reporting Time:+125.87 h5.245 days <br />0.749 weeks <br />0.172 months <br />)
Opened:	Tyler Kruse 11:52 Feb 7, 2020
NRC Officer:	Andrew Waugh
Last Updated:	Feb 7, 2020
54514 - NRC Website
v • d • e

v t e Emergency Notification System
Minnesota Department of Health with Agreement State
WEEKMONTHYEAR		Agreement State Report - Report of Lost Static Eliminator 2023-04-20T05:00:00 [Table view]
[ENS list for Minnesota Department of Health]

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