ENS 57631

v t e ENS Event
04:00 Mar 25, 2025
Title	Medical Event
Event Description	The following information was received by the Ohio Department of Health via email: A patient was scheduled to receive 200 mCi of PLUVICTO [Lu-177], however, they only received approximately 130 mCi [administered to the prostate]. The injection was through a three-way stopcock; one port was for the saline solution, the other for the PLUVICTO. Near the end of the injection, the material back flowed into the syringe and leaked onto the chucks under the patient's arm. Based on surveys of the syringe and chucks, approximately 70 mCi had leaked which resulted in a 35 percent underdose. The patient was surveyed and there was no indication the patient's skin was contaminated or signs of extravasation. The patient's physician was notified of the event. An investigation by Ohio is pending. NMED Report Number: OH250003 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 57631 +/-
Where
Cleveland Clinic Foundation Cleveland, Ohio (NRC Region 3)
License number:	02110180013
Organization:	Ohio Bureau Of Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+54.03 h2.251 days <br />0.322 weeks <br />0.074 months <br />)
Opened:	Michael J. Rubadue 10:02 Mar 27, 2025
NRC Officer:	Ernest West
Last Updated:	Mar 27, 2025
57631 - NRC Website
v • d • e

v t e Emergency Notification System
Cleveland Clinic Foundation with Agreement State
WEEKMONTHYEAR2025-03-25T04:00:00 [Table view]
[ENS list for Cleveland Clinic Foundation]

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