ENS 56930
ENS Event | |
|---|---|
20:00 Jan 19, 2024 | |
| Title | Y-90 Microsphere Misadministration |
| Event Description | The following is a summary of information received via email from the Washington Office of Radiation Protection:
On the afternoon of Friday, January 19th, a Pluvicto (radiopharmaceutical) dose was not administered properly. A typical administered dose may have up to 2 to 4 mCi of residual activity after a 200 mCi administration. However, for this administration there was 43 mCi of residual activity and only 149 mCi of calculated administered activity for a 200 mCi prescribed dose. Pluvicto is a six fraction, six administration regimen with about six weeks between each administration, and this was the patient's fourth fractional dose. Treated as a single administration treatment, this constitutes a medical event as the dose administered activity of 149 mCi is more than 20% less than the 200 mCi prescribed dose. The final report will be sent in 15 days. Washington Event Number: WA-24-003 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.
The following information is a synopsis of information provided by the Washington State Radioactive Materials Section: A lutetium 177 (drug name: Pluvicto) dose was prescribed to be 200 mCi. The calculated dose administered to the patient was about 149 mCi, based upon the measured residual. The underdosing occurred due to a method of folding and crimping the intravenous tube with a hemostat and gauze instead of utilizing the kit provided clamp. The hospital supply chain of the intravenous kit was recently changed and the needed clamp was thought to be missing. To prevent future crimping of the intravenous tube, the use of hemostat and gauze will no longer be used. This dose was the fourth dose of six prescribed to the patient, with six weeks between each administration. There is no expected change in the patient's treatment or prognosis based on the underdosing of the fourth fraction of six and no additional actions are required. Final report will be sent in 15 days. Washington Event Number: WA-24-003 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. Notified R4DO (Agrawal) and NMSS (email). |
| Where | |
|---|---|
| Swedish Medical Center Seattle, Washington (NRC Region 4) | |
| License number: | WN-M008 |
| Organization: | Wa Office Of Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+70.18 h2.924 days <br />0.418 weeks <br />0.0961 months <br />) | |
| Opened: | Boris Tsenov 18:11 Jan 22, 2024 |
| NRC Officer: | Brian P. Smith |
| Last Updated: | Jan 31, 2024 |
| 56930 - NRC Website | |
Swedish Medical Center with Agreement State | |
WEEKMONTHYEARENS 569302024-01-19T20:00:00019 January 2024 20:00:00
[Table view]Agreement State Y-90 Microsphere Misadministration ENS 540222019-04-23T07:00:00023 April 2019 07:00:00 Agreement State Washington Agreement State Report - Lost and Found Radioactive Material ENS 538042018-12-19T08:00:00019 December 2018 08:00:00 Agreement State En Revision Imported Date 1/18/2019 ENS 537942018-12-15T07:00:00015 December 2018 07:00:00 Agreement State Agreement State Report - Medical Misadministration ENS 533772018-01-23T18:30:00023 January 2018 18:30:00 Agreement State Agreement State Report - Patient Received Dose Less than Prescribed Dose ENS 435352007-07-17T17:00:00017 July 2007 17:00:00 Agreement State Agreement State Report - Six Lost Palladium - 103 Seeds ENS 415012005-03-17T20:00:00017 March 2005 20:00:00 Agreement State Argeement State Medical Event ENS 410782004-09-24T07:00:00024 September 2004 07:00:00 Agreement State Agreement State Report ENS 403372003-11-17T08:00:00017 November 2003 08:00:00 Agreement State Patient Received an Overdose During a Brachytherapy Procedure 2024-01-19T20:00:00 | |