ENS Event | |
|---|---|
05:00 Jul 30, 2019 | |
| Title | Agreement State Report - Incorrect Dosage Administered |
| Event Description | The following was received via email:
On August 19, 2019, the Agency [Texas Department of State Health Services] was notified by the licensee's radiation safety officer (RSO) that a medical event had occurred. The event occurred on a patient who was prescribed to receive four treatments of lutetium-177 at 200 milliCuries each. After the third treatment, the physician was supposed to change the dose of the fourth and final dose to 100 milliCuries. The radiopharmaceutical was ordered, and the dose was administered. The RSO stated that during the review of the patient's treatment, they found the pharmacy had sent a unit dose of 200 milliCuries instead of the requested 100 milliCuries. The RSO stated both the prescribing physician and the patient were notified of the error. No adverse effects are expected on the patient. The Agency has requested additional information on this event. Additional information will be provided as it is received in accordance with SA-300.
On August 20, 2019, the licensee contacted the Agency and stated the treatment site was the mid-gut. The treatment was conducted on July 30, 2019. The error was discovered the day of the event. Additional information will be provided as it is received in accordance with SA-300. 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 | |
|---|---|
| Texas Oncology Pa Dallas, Texas (NRC Region 4) | |
| License number: | L04878 |
| Organization: | Texas Dept Of State Health Services |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+510.32 h21.263 days <br />3.038 weeks <br />0.699 months <br />) | |
| Opened: | Art Tucker 11:19 Aug 20, 2019 |
| NRC Officer: | Bethany Cecere |
| Last Updated: | Aug 20, 2019 |
| 54231 - NRC Website | |
Texas Oncology Pa with Agreement State | |
WEEKMONTHYEARENS 542312019-07-30T05:00:00030 July 2019 05:00:00
[Table view]Agreement State Agreement State Report - Incorrect Dosage Administered ENS 539322019-03-07T05:00:0007 March 2019 05:00:00 Agreement State Agreement State Report - Misadministration of Dose to Patient ENS 538362019-01-18T06:00:00018 January 2019 06:00:00 Agreement State En Revision Imported Date 2/22/2019 ENS 532262018-02-21T06:00:00021 February 2018 06:00:00 Agreement State Agreement State Report - Medical Event 2019-07-30T05:00:00 | |