ENS Event | |
|---|---|
05:00 Jul 21, 2022 | |
| Title | Medical Event |
| Event Description | The following was received from the Minnesota Department of Health via email:
A patient was prescribed 100 mCi of Lu-177 Lutathera to treat a metastatic neuroendocrine tumor. On 7/21/2022, the patient received their therapy and was administered 206 mCi by mistake. The root cause of this event is unknown at this time and is being investigated. Based on the additional 106 mCi administration, the licensee calculated the additional whole body effective dose equivalent to be 30.1 rems using ICRP 103 methodology. MN Event Report ID No. MN330003 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 | |
|---|---|
| Mayo Clinic Rochester, Minnesota (NRC Region 3) | |
| License number: | 1047 |
| Organization: | Minnesota Department Of Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+31.22 h1.301 days <br />0.186 weeks <br />0.0428 months <br />) | |
| Opened: | Tyler Kruse 12:13 Jul 22, 2022 |
| NRC Officer: | Lloyd Desotell |
| Last Updated: | Jul 22, 2022 |
| 56010 - NRC Website | |
Mayo Clinic with Agreement State | |
WEEKMONTHYEARENS 566712023-08-09T04:00:0009 August 2023 04:00:00
[Table view]Agreement State Lost Shipment ENS 563332022-12-16T06:00:00016 December 2022 06:00:00 Agreement State Lost Source ENS 561562022-09-28T05:00:00028 September 2022 05:00:00 Agreement State Medical Misadminstration ENS 561372022-09-27T05:00:00027 September 2022 05:00:00 Agreement State Patient Underdose ENS 560102022-07-21T05:00:00021 July 2022 05:00:00 Agreement State Medical Event ENS 553892021-07-29T05:00:00029 July 2021 05:00:00 Agreement State Ageement State Report - Medical Event ENS 552672021-05-18T05:00:00018 May 2021 05:00:00 Agreement State Patient Underdose ENS 556552020-03-17T06:00:00017 March 2020 06:00:00 Agreement State Lost Brachytherapy Seed ENS 533382018-04-13T04:00:00013 April 2018 04:00:00 Agreement State Florida Agreement State Report - Patient Received 65 Percent of Prescribed Dose to Intended Treatment Site ENS 528782017-07-28T04:00:00028 July 2017 04:00:00 Agreement State Agreement State Report - Dose Received Exceeded Prescribed Dose ENS 510252015-04-29T05:00:00029 April 2015 05:00:00 Agreement State Agreement State Report - Medical Underdose ENS 464122010-11-10T17:00:00010 November 2010 17:00:00 Agreement State Agreement State Report - Underdosage to Intended Treatment Area ENS 457882010-03-23T05:00:00023 March 2010 05:00:00 Agreement State Agreement State Report - Improper Dosage Given During Medical Treatment ENS 449492009-03-31T04:00:00031 March 2009 04:00:00 Agreement State Agreement State Report - Lost I-125 Seed 2023-08-09T04:00:00 | |