ENS Event | |
|---|---|
05:00 Apr 6, 2026 | |
| Title | Medical Event |
| Event Description | The following information was provided by Wisconsin Department of Health Services (the Department) via phone and email:
On April 6, 2026, a patient was receiving the sixth of six administrations of Lu-177 (Pluvicto). The first five administrations had been prescribed at 200 mCi. All were delivered in accordance with their written directive. The sixth administration prescribed a reduced dosage of 160 mCi. The licensee administered a dosage of 199.4 mCi, 25 percent greater than the written directive. While performing a written directive review following the administration, the licensee identified that the incorrect dosage was administered, and it was immediately reported to the licensee's office of radiation safety. The referring physician and the patient were both notified of the medical event. The referring physician does not believe the increased dosage will have any adverse effects on the patient. The licensee is preparing a written report for the Department. The Department will follow up with an investigation. Wisconsin event report number: WI260007 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 | |
|---|---|
| Medical College Of Wisconsin Milwaukee, Wisconsin (NRC Region 3) | |
| License number: | 079-1104-01 |
| Organization: | Wisconsin Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+34.12 h1.422 days <br />0.203 weeks <br />0.0467 months <br />) | |
| Opened: | Kyle Walton 15:07 Apr 7, 2026 |
| NRC Officer: | Tenisha Meadows |
| Last Updated: | Apr 7, 2026 |
| 58236 - NRC Website | |
Medical College Of Wisconsin with Agreement State | |
WEEKMONTHYEARENS 582362026-04-06T05:00:0006 April 2026 05:00:00
[Table view]Agreement State Medical Event ENS 574752024-09-19T06:00:00019 September 2024 06:00:00 Agreement State Lost Source ENS 564052023-03-09T06:00:0009 March 2023 06:00:00 Agreement State Found Source ENS 459992010-06-10T05:00:00010 June 2010 05:00:00 Agreement State Agreement State Report - Brachytherapy Dose Received Was Greater than 20% of Prescribed Dose 2026-04-06T05:00:00 | |