ENS Event | |
|---|---|
05:00 Nov 9, 2018 | |
| Title | Patient Underdosage Due to Loss of Air Seal Integrity |
| Event Description | Today, Nov 9, 2018 a medical event occurred at our facility in which 145.7 mCi of Lutathera Lutetium-177 was delivered out of the prescribed 200 mCi. The full dose could not be delivered as there was loss of integrity of the air seal on the Lutathera vial.
The licensee indicated the cause of the event was still under investigation and the Doctor and patient were informed of the issue. The licensee has not notified the Region III office. 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 | |
|---|---|
| Gershenson Radiation Oncology Center Detroit, Michigan (NRC Region 3) | |
| License number: | 21-04127-06 |
| Organization: | Karmanos Cancer Center |
| Reporting | |
| 10 CFR 35.3045(a)(1) | |
| Time - Person (Reporting Time:+11.35 h0.473 days <br />0.0676 weeks <br />0.0155 months <br />) | |
| Opened: | Joe Rakowski 16:21 Nov 9, 2018 |
| NRC Officer: | Jeff Herrera |
| Last Updated: | Nov 9, 2018 |
| 53728 - NRC Website | |
Gershenson Radiation Oncology Center with 10 CFR 35.3045(a)(1) | |
WEEKMONTHYEARENS 537282018-11-09T05:00:0009 November 2018 05:00:00
[Table view]10 CFR 35.3045(a)(1) Patient Underdosage Due to Loss of Air Seal Integrity 2018-11-09T05:00:00 | |