ENS Event | |
|---|---|
05:00 Feb 1, 2024 | |
| Title | Medical Misadministration |
| Event Description | The following information was provided by the Pennsylvania Department of Environmental Protection Bureau of Radiation Protection (the Department) email:
On February 1, 2024, a patient was receiving a lutetium-177 (Lutathera) treatment. The written directive, signed by the authorized user (AU), was for 200 mCi of Lu-177. However, the treating medical oncologist signed a 100 mCi dose alteration treatment plan order on the same day as the procedure. The patient received the 200 mCi dose that was recorded in the written directive instead of what was intended. It is believed that miscommunication occurred between the two, and a full investigation into the cause of the event is underway by the licensee. The AU and the patient have been notified. No harmful effects are expected to patient. The Department will update this event as soon as more information is provided. 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 | |
|---|---|
| Hospital Of Fox Chase Cancer Center Philadelphia, Pennsylvania (NRC Region 1) | |
| License number: | PA-0293 |
| Organization: | Pa Bureau Of Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+369.48 h15.395 days <br />2.199 weeks <br />0.506 months <br />) | |
| Opened: | John Chippo 14:29 Feb 16, 2024 |
| NRC Officer: | Sam Colvard |
| Last Updated: | Feb 16, 2024 |
| 56972 - NRC Website | |
Hospital Of Fox Chase Cancer Center with Agreement State | |
WEEKMONTHYEARENS 569722024-02-01T05:00:0001 February 2024 05:00:00
[Table view]Agreement State Medical Misadministration 2024-02-01T05:00:00 | |