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| Entered date | Event description | |
|---|---|---|
| ENS 55817 | 1 April 2022 14:25:00 | The following information was provided by the licensee via telephone and email: Two clinical doses of Xofigo ((radium (Ra-223) dichloride, 119 microcuries)) were delivered to the Nuclear Medicine department on 3/31/2022. A patient scheduled for one of the doses on Thursday 3/31/2022 was successfully administered with the activity. A second patient was scheduled to receive the second dose on 4/1/2022 at 1300 EDT. At scheduled time, the Nuclear Medicine technologists could not locate the second dose. After a thorough search, the RSO ((Radiation Safety Officer)) was notified. It is suspected that the second dose was accidentally disposed of in the box in which both doses were received. The first dose was properly disposed of in a radioactive sharps container, and the second dose remained in the delivery box within the secured hot lab area. It is suspected that a nuclear medicine technologist threw the box away without realizing a second dose was inside, as it is an extremely rare occurrence for two doses to be delivered concurrently. The dose was not detected during the end of day survey nor by portal monitoring at the waste facility, due to the relatively low activity and low yield of x-rays/gamma-rays (Ra-223 is primarily an alpha emitter). THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf |
| ENS 54946 | 13 October 2020 14:49:00 | The following is a summary from a phone call with the licensee: A patient at the Indiana University Health Methodist Hospital was prescribed 46.7 mCi of Y-90 Theraspheres to segments 5 and 8 of the liver, but received 54 percent (25.2 mCi) of the prescribed dose. The remaining 46 percent (21.5 mCi) was trapped in the catheter or the line. The patient and the physician were notified and a follow-up treatment has been scheduled for next week. 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 53574 | 31 August 2018 14:28:00 | A patient was prescribed 86.9 milliCuries Yittrium-90 Theraspheres to the liver, but a malfunction in the kit prevented the Theraspheres from travelling to the dose location. There was no contamination detected on the patient or equipment. The patient was notified and rescheduled for this procedure next week. The manufacturer of the kit was notified and the hospital pulled all kits in that lot. 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. |