ENS Event | |
|---|---|
05:00 Jan 27, 2025 | |
| Title | Medical Event |
| Event Description | The following information was provided by the Ohio Department of Health via email:
On January 28, 2025, the Ohio Department of Health, Bureau of Environmental Health and Radiation Protection was notified by University Hospitals of Cleveland that during a therapeutic infusion of Pluvicto (Lu-177) [that was administered on January 27, 2025], 60.9 mCi of a total dose of 295 mCi was extravasated in the patient's right arm antecubital area [i.e. not the intended treatment site]. The licensee calculated a 0.61 Gy dose to the skin near the extravasation site based on imaging taken from 20 minutes to 22 hours2.546296e-4 days <br />0.00611 hours <br />3.637566e-5 weeks <br />8.371e-6 months <br /> post-infusion. At 22 hours2.546296e-4 days <br />0.00611 hours <br />3.637566e-5 weeks <br />8.371e-6 months <br /> post infusion, 0.46 mCi remained around the injection site based on imaging. The authorized user believes the material has drained through the lymphatic system to the prostate. Ohio Item Number: OH250001 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 | |
|---|---|
| University Hospitals of Cleveland Cleveland, Ohio (NRC Region 3) | |
| License number: | 02110180077 |
| Organization: | Ohio Bureau Of Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+55.85 h2.327 days <br />0.332 weeks <br />0.0765 months <br />) | |
| Opened: | Michael J. Rubadue 12:51 Jan 29, 2025 |
| NRC Officer: | Ernest West |
| Last Updated: | Jan 30, 2025 |
| 57520 - NRC Website
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University Hospitals of Cleveland with Agreement State | |
WEEKMONTHYEARENS 575202025-01-27T05:00:00027 January 2025 05:00:00
[Table view]Agreement State Medical Event ENS 551522019-06-12T04:00:00012 June 2019 04:00:00 Agreement State Failure to Report Underdose to Patient ENS 512332015-07-14T14:30:00014 July 2015 14:30:00 Agreement State Agreement State Report - Dose to Improper Treatment Site ENS 449732008-12-15T04:00:00015 December 2008 04:00:00 Agreement State Incident Involving Co-60 Gamma Knife During Patient Treatment 2025-01-27T05:00:00 | |