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. |
| 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 | |
Cleveland Clinic Foundation with Agreement State | |
WEEKMONTHYEARENS 576312025-03-25T04:00:00025 March 2025 04:00:00
[Table view]Agreement State Medical Event ENS 551572021-03-26T18:00:00026 March 2021 18:00:00 Agreement State Medical Event Report - Underdosage ENS 536722018-10-16T04:00:00016 October 2018 04:00:00 Agreement State En Revision Imported Date 7/24/2019 ENS 498152014-01-24T05:00:00024 January 2014 05:00:00 Agreement State Agreement State Report - Medical Event Involving Unintended Dose ENS 470712011-07-12T15:00:00012 July 2011 15:00:00 Agreement State Agreement State Report - Patient Received Treatment to Incorrect Organ ENS 465722010-12-08T05:00:0008 December 2010 05:00:00 Agreement State Agreement State Report - Potential Underdose to Patient Due to Aborted Treatment ENS 463762010-10-29T04:00:00029 October 2010 04:00:00 Agreement State Agreement State - Dose Delivered to Wrong Organ ENS 462862010-09-27T04:00:00027 September 2010 04:00:00 Agreement State Ohio Agreement State Report - 95% Medical Underdosage Due to Equipment Failure ENS 443972008-08-07T18:00:0007 August 2008 18:00:00 Agreement State Agreement State Report - Underexposure During Hdr Medical Treatment Due to Equipment Malfunction ENS 405752004-03-04T21:00:0004 March 2004 21:00:00 Agreement State the Cleveland Clinic Foundation Administered an Underdose During a Therapeutic Treatment 2025-03-25T04:00:00 | |