ENS 56400
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ENS Event | |
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05:00 Mar 7, 2023 | |
Title | Misapplication of Medical Dose Resulting in Underdosing |
Event Description | The following information was provided by the Ohio Bureau of Environmental Health and Radiation Protection via email:
Ohio State University reported a medical event on March 8, 2023. A written directive for 200 millicuries of lutetium-177 (PLUVICTO) to be administered intravenously was signed by an authorized user. The dosage was assayed at 195.57 millicures and was administered to the patient on March 7, 2023. During the administration, the Nuclear Medicine Technologist noted some drips from the tubing. An investigation was initiated and the results on March 8, 2023, indicate the patient received 157.57 millicuries of lutetium-177 (PLUVICTO), 21.5 percent less than the written directive. The investigation will continue to determine the root cause of the medical event and determine corrective actions if applicable. Reference Number OH 2023-006 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 | |
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Ohio State University Columbus, Ohio (NRC Region 3) | |
License number: | 02110250037 |
Organization: | Ohio Bureau Of Radiation Protection |
Reporting | |
Agreement State | |
Time - Person (Reporting Time:+58.6 h2.442 days <br />0.349 weeks <br />0.0803 months <br />) | |
Opened: | Michael Snee 15:36 Mar 9, 2023 |
NRC Officer: | John Russell |
Last Updated: | Mar 9, 2023 |
56400 - NRC Website
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Ohio State University with Agreement State | |
WEEKMONTHYEARENS 566842023-07-28T04:00:00028 July 2023 04:00:00
[Table view]Agreement State Treatment to Wrong Side of Organ ENS 564002023-03-07T05:00:0007 March 2023 05:00:00 Agreement State Misapplication of Medical Dose Resulting in Underdosing ENS 552482021-05-10T05:00:00010 May 2021 05:00:00 Agreement State Dose to Improper Treatment Site ENS 542092019-08-06T04:00:0006 August 2019 04:00:00 Agreement State Agreement State Report - Leaking Eckert & Ziegler Cs-137 Vial Source ENS 458642010-04-20T04:00:00020 April 2010 04:00:00 Agreement State Agreement State Report - Possible Overexposure to a Member of the Public 2023-07-28T04:00:00 | |
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