ENS 58050
ENS Event | |
|---|---|
00:51 Nov 20, 2025 | |
| Title | Medical Event |
| Event Description | The following is a summary of the information provided by the Washington State Department of Health Office of Radiation Protection (Department) via email:
At 1651 PST, the Department was notified of the misadministration of a 200 mCi Lu-177 prostate membrane specific antigen dose for a patient on a research protocol. The dose was administered using an infusion pump. The principal investigator (PI) of the study was present for the administration and verified the dose. The PI is an authorized user on the license. The pump began malfunctioning shortly after the infusion began. There were attempts to reset the pump and change the pump and patient catheter lines, but the situation did not improve. The decision was made to abort the procedure due to the ongoing difficulties. It is believed that the infusion lines failed due to blockage or pressure buildup, which caused the pump to alarm. A small amount of contamination was noted on the infusion pump stand, on a side table that held the infusion lines, as well as near the sink in the room, likely due to initial decontamination efforts. The room was easily decontaminated and reopened. Residuals measured from the remaining vial and tubing totaled approximately 145 mCi. The patient had imaging immediately after the aborted infusion that confirmed some administration of the drug was successful, which was estimated at 55 mCi. This represents 27.5 percent of the prescribed dose injected. The research protocol includes an additional dose. Patient protocols are being reviewed for possible changes. A detailed report will follow within 15 days. WA incident number: WA-25-015 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 | |
|---|---|
| Fred Hutchinson Cancer Center Seattle, Washington (NRC Region 4) | |
| License number: | WN-M0225 |
| Organization: | Wa Office Of Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+-10.68 h-0.445 days <br />-0.0636 weeks <br />-0.0146 months <br />) | |
| Opened: | Dan Blakinger 14:10 Nov 19, 2025 |
| NRC Officer: | Jordan Wingate |
| Last Updated: | Nov 19, 2025 |
| 58050 - NRC Website
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Fred Hutchinson Cancer Center with Agreement State | |
WEEKMONTHYEARENS 580502025-11-20T00:51:00020 November 2025 00:51:00
[Table view]Agreement State Medical Event ENS 563102022-12-14T08:00:00014 December 2022 08:00:00 Agreement State Two Under Doses and Contaminated Individual 2025-11-20T00:51:00 | |