ENS 56717

v t e ENS Event
19:00 Sep 5, 2023
Title	Patient Received 29 Percent Overdose
Event Description	The following was received from the Colorado Department of Public Health and Environment via email: The Radiation Safety Officer (RSO) reported at 1530 MDT on 9/5/23 that at about 1300 MDT on 9/5/23, a nuclear medicine technologist administered 206.7 mCi of Lu-177 PSMA (Pluvicto) to a patient, however the prescribed dosage on the written directive was only 160 mCi. The total dose delivered differed from the prescribed dose by 29 percent exceeding the threshold of 20 percent. The RSO indicated that the technician did not follow the written directive to verify the dose before injection because this type of treatment usually requires 200 mCi. At 1906 MDT on 9/5/23, the RSO provided a dose calculation that indicated the delivered dose differs from the prescribed dose by 0.49 Sv effective dose equivalent (more than the 0.05 Sv threshold) and 0.5-3.5 Sv to multiple organs (more than the 0.5 Sv threshold). A written report is required within 15 days of September 5, 2023. Colorado Event Report ID No.: CO230028 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 56717 +/-
Where
Uc Health University Aurora, Colorado (NRC Region 4)
License number:	CO 828-01
Organization:	Colorado Dept Of Health
Reporting

Agreement State
Time - Person (Reporting Time:+16.02 h0.668 days <br />0.0954 weeks <br />0.0219 months <br />)
Opened:	Shiya Wang 11:01 Sep 6, 2023
NRC Officer:	Thomas Herrity
Last Updated:	Sep 6, 2023
56717 - NRC Website
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v t e Emergency Notification System
Uc Health University with Agreement State
WEEKMONTHYEAR2023-09-05T19:00:00 [Table view]
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