ENS Event | |
|---|---|
04:00 Jul 22, 2021 | |
| Title | Patient Under Dose |
| Event Description | The following was received via an email from the Pennsylvania Department of Environmental Protection (DEP) via email:
On July 22, 2021 a patient was receiving a Lutetium-177 (Lutathera) treatment when technicians had difficulty establishing an IV injection site and flow. Several attempts were made, but ultimately they all failed. The prescribed dose was 200 milliCuries, but it is estimated that the patient received only 18 millicuries. No adverse effects to the patient are noted at this time and none are expected. The patient and prescribing physician have been informed. Preliminary cause is suspected to be poor venous access for patient as well as incorrect gauge needle used for patient access. The DEP will update this event as soon as more information is provided. The Department will perform a reactive inspection. Pennsylvania Event Report ID No: PA210008 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 | |
|---|---|
| Geisinger Health System Danville, Pennsylvania (NRC Region 1) | |
| License number: | PA-0006 |
| Organization: | Pa Bureau Of Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+33 h1.375 days <br />0.196 weeks <br />0.0452 months <br />) | |
| Opened: | John Chippo 13:00 Jul 23, 2021 |
| NRC Officer: | Lloyd Desotell |
| Last Updated: | Jul 23, 2021 |
| 55376 - NRC Website | |
Geisinger Health System with Agreement State | |
WEEKMONTHYEARENS 563192023-01-11T05:00:00011 January 2023 05:00:00
[Table view]Agreement State Patient Underdose ENS 553762021-07-22T04:00:00022 July 2021 04:00:00 Agreement State Patient Under Dose ENS 530732017-11-15T05:00:00015 November 2017 05:00:00 Agreement State Agreement State Report - Incorrect Written Directive for Liver Patient ENS 515902015-12-04T05:00:0004 December 2015 05:00:00 Agreement State Agreement State Report - Delivered Dose of Yttrium-90 Less than Prescribed Dose 2023-01-11T05:00:00 | |