ENS 56972

v t e ENS Event
05:00 Feb 1, 2024
Title	Medical Misadministration
Event Description	The following information was provided by the Pennsylvania Department of Environmental Protection Bureau of Radiation Protection (the Department) email: On February 1, 2024, a patient was receiving a lutetium-177 (Lutathera) treatment. The written directive, signed by the authorized user (AU), was for 200 mCi of Lu-177. However, the treating medical oncologist signed a 100 mCi dose alteration treatment plan order on the same day as the procedure. The patient received the 200 mCi dose that was recorded in the written directive instead of what was intended. It is believed that miscommunication occurred between the two, and a full investigation into the cause of the event is underway by the licensee. The AU and the patient have been notified. No harmful effects are expected to patient. The Department will update this event as soon as more information is provided. PA NMED Event Number: PA240005 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 56972 +/-
Where
Hospital Of Fox Chase Cancer Center Philadelphia, Pennsylvania (NRC Region 1)
License number:	PA-0293
Organization:	Pa Bureau Of Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+369.48 h15.395 days <br />2.199 weeks <br />0.506 months <br />)
Opened:	John Chippo 14:29 Feb 16, 2024
NRC Officer:	Sam Colvard
Last Updated:	Feb 16, 2024
56972 - NRC Website
v • d • e

v t e Emergency Notification System
Hospital Of Fox Chase Cancer Center with Agreement State
WEEKMONTHYEAR2024-02-01T05:00:00 [Table view]
[ENS list for Hospital Of Fox Chase Cancer Center]

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