ENS Event | |
|---|---|
05:00 Mar 3, 2022 | |
| Title | Agreement State - Underdose |
| Event Description | The following was received from the Commonwealth of Pennsylvania, Department of Environmental Protection (DEP) via e-mail:
On March 3, 2022 a patient was receiving a Lutetium-177 (Lutatherar) treatment. During treatment, the vial lost pressure resulting in the inability to deliver the majority of the dose to the patient. Remedial measures were attempted, such as Dermabond and the addition of air, however, the procedure still could not continue, and it was terminated. No contamination was found outside of the delivery box. The prescribed dose was 200 milliCuries and it is estimated that the patient received 1.4 milliCuries. An investigation into the cause of the event is underway by the licensee. No adverse effects to the patient are noted at this time and the patient and prescribing physician have been informed. The DEP will update this event as soon as more information is provided. PA Event Report ID No: PA220009 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 | |
|---|---|
| Reading Hospital Reading, Pennsylvania (NRC Region 1) | |
| License number: | PA-0023 |
| Organization: | Pa Bureau Of Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+30.38 h1.266 days <br />0.181 weeks <br />0.0416 months <br />) | |
| Opened: | John Chippo 11:23 Mar 4, 2022 |
| NRC Officer: | Thomas Herrity |
| Last Updated: | Mar 4, 2022 |
| 55766 - NRC Website | |
Reading Hospital with Agreement State | |
WEEKMONTHYEARENS 557662022-03-03T05:00:0003 March 2022 05:00:00
[Table view]Agreement State Agreement State - Underdose ENS 512372015-07-15T04:00:00015 July 2015 04:00:00 Agreement State Agreement State Report - Overdose to Patient During Prostate Seed Implant 2022-03-03T05:00:00 | |