ENS 55441

v t e ENS Event
05:00 Jul 12, 2021
Title	Agreement State - Incorrect Radiopharmaceutical Administered
Event Description	The following was received from the Texas Department of State Health Services (the Agency) via email: On August 31, 2021, the Agency received a notification from the Nuclear Regulatory Commission (NRC) stating that a Missouri supplier of radiopharmaceuticals had reported a misadministration that occurred on July 12, 2021, with one of their products at a Texas licensee. The licensee contacted the Agency to report the event shortly after receiving the notification from the NRC. The licensee stated that a patient was to receive 0.041 mCi of Th-227 with enzymes to affect breast cancer but was given 0.041 mCi of Th-227 with enzymes to affect mesothelioma. The event resulted in approximately 6 Gy dose to the liver. The patient refused a post therapy scan and the licensee was not able to confirm that the radiopharmaceutical went to the correct tissue in the body. The mislabeling was discovered by the radiopharmaceutical supplier who then notified the licensee that the drug administered was not correct. The licensee has notified the patient and physician. Additional information will be provided as it is received in accordance with SA-300. Texas Incident Number: 9882 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 55441 +/-
Where
The University Of Texas Md Anderson Cancer Center Houston, Texas (NRC Region 4)
License number:	L 00466
Organization:	Texas Dept Of State Health Services
Reporting

Agreement State
Time - Person (Reporting Time:+1212.03 h50.501 days <br />7.214 weeks <br />1.66 months <br />)
Opened:	Matt Kennington 17:02 Aug 31, 2021
NRC Officer:	Mike Stafford
Last Updated:	Aug 31, 2021
55441 - NRC Website
v • d • e

v t e Emergency Notification System
The University Of Texas Md Anderson Cancer Center with Agreement State
WEEKMONTHYEAR2022-05-06T05:00:00 [Table view]
[ENS list for The University Of Texas Md Anderson Cancer Center]

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