The following information was provided by the
Florida Bureau of Radiation Control (FL
BRC) via email:
Today, 3/10/2022, at 1000 EST, Lutathera treatment was started in a controlled infusion room within the nuclear medicine department of Moffitt Cancer Center with an initial vial assay of 206 mCi, approximately two minutes later the NMT [(nuclear medicine technologist)] noticed a leak in the infusion line and stopped the infusion. Assistance was provided by a fellow technologist and the vial of Lutathera (Lu-177) was re-assayed at 130 mCi. The floor lead technologist notified the prescribing physician and the physician decided to terminate the treatment and to re-treat at a later date. Wipe tests performed by the technologists on the patient including the arm where the IV was showed no evidence of removable contamination. The department supervisor was notified and called the radiation safety officer (RSO) at 1030 EST. The IV was removed from the patient and the tubing was assayed at 36 mCi. The infusion room was surveyed and appropriately decontaminated. Residual waste from decontamination, as well as the vial, lead vial container, and IV/tubing were logged, labeled, and placed into secure storage. An investigation into the cause of the incident will be completed, and corrective actions will be implemented to prevent reoccurrence.
The prescribing physician spoke with the patient and explained what happened and that there would not be any clinical impact on the patient and no medical risks.
The referring physician was notified.
A written report will be provided to the FL BRC, the referring physician, and the individual within 15 days of this event in accordance to 64E-5.345 4(b).
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.