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. |
| 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 | |
The University Of Texas Md Anderson Cancer Center with Agreement State | |
WEEKMONTHYEARENS 558862022-05-06T05:00:0006 May 2022 05:00:00
[Table view]Agreement State Three Medical Events - Underdoses ENS 554412021-07-12T05:00:00012 July 2021 05:00:00 Agreement State Agreement State - Incorrect Radiopharmaceutical Administered ENS 508622015-03-03T22:01:0003 March 2015 22:01:00 Agreement State Agreement State Report - Irradiator Source Would Not Fully Lower to Shielded Position 2022-05-06T05:00:00 | |