ENS Event | |
|---|---|
06:00 Feb 2, 2020 | |
| Title | Agreement State Report - Medical Event |
| Event Description | The following was received from the state of Minnesota via email:
Lu-177 administration was performed on February 4, 2020. The administration team did not start the patient on amino acids prior to the administration. Upon discovery of the error, the acids were started. This resulted in an unintended dose to the kidneys. The Radiation Safety Officer (RSO) and staff were notified on February 5, 2020. They determined it was a medical event on February 7, 2020 at 0930 CST. The event was reported to the Minnesota Department of Health (MDH) at 1000 CST on February 7, 2020. The intended dose to the kidney was 490 Rem. The delivered dose to the kidney was 740 Rem (this was their 'best case scenario' calculation). This would fall under 4731.4525 Subpart 1 Item C.: 'a dose to the skin or an organ or tissue other than the treatment site that exceeds 50 Rem and exceeds 50 percent of the dose expected from the administration defined in the written directive.' This event is still under investigation with MDH. Minnesota Event Report ID: MN200002 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 | |
|---|---|
| Minnesota Department Of Health Rochester, Minnesota (NRC Region 3) | |
| License number: | 1047 |
| Organization: | Minnesota Department Of Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+125.87 h5.245 days <br />0.749 weeks <br />0.172 months <br />) | |
| Opened: | Tyler Kruse 11:52 Feb 7, 2020 |
| NRC Officer: | Andrew Waugh |
| Last Updated: | Feb 7, 2020 |
| 54514 - NRC Website | |
Minnesota Department Of Health with Agreement State | ||
WEEKMONTHYEARENS 564932023-04-20T05:00:00020 April 2023 05:00:00 Agreement State Found Source ENS 551862021-04-01T05:00:0001 April 2021 05:00:00 Agreement State Dose Administered Greater than Prescribed ENS 549332020-10-05T05:00:0005 October 2020 05:00:00 Agreement State | Agreement State Report - Report of Lost Static Eliminator ENS 545142020-02-02T06:00:0002 February 2020 06:00:00 Agreement State Agreement State Report - Medical Event 2023-04-20T05:00:00 [Table view] | |