ENS Event | |
|---|---|
19:00 Sep 24, 2025 | |
| Title | Medical Event |
| Event Description | The following information was provided by the California Department of Public Health, Radiologic Health Branch (RHB) via email:
The University of California Los Angeles (UCLA) reported to RHB that a reportable medical event (underdose) had occurred on September 24, 2025. A patient was to receive 200 mCi of Lu-177 Lutathera for a neuroendocrine tumor via an intravenous line and a mechanical infusion pump. However, it was calculated that the patient only received 80 mCi of the intended dose. The registered nurse starts the IV (3-way connections), and the patient receives amino acids for the first hour. Next, a certified nuclear medicine technologist (CNMT) connects the syringe of Lutathera and connects it to the pump. It takes 45 minutes to complete the infusion, and the pump increases its pressure over time. Upon returning to remove the syringe and restarting the amino acid drip, the CNMT noticed the IV had leaked onto the chux [pad] and a small part of the patient's arm skin. The medical radiation safety officer (RSO) was notified and reported to the patient's treatment room. The patient's arm was decontaminated, and the medical physicist calculated the patient had approximately 2-4 mCi on their skin (estimated 30-60 rem skin dose). The Lu-177 contaminated chux materials were collected and evaluated by the nuclear medicine department to contain approximately 120 mCi of the leaked dose. UCLA's initial investigation indicates that the increasing pressure from the infusion pump allowed the IV connection to become loose and leak. RHB will continue to follow-up with UCLA and receive their full event report. California 5010 Number: 092425 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 | |
|---|---|
| Ucla Los Angeles, California (NRC Region 4) | |
| License number: | 1335-19 |
| Organization: | California Radiation Control Prgm |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+24.77 h1.032 days <br />0.147 weeks <br />0.0339 months <br />) | |
| Opened: | Donald Oesterle 19:46 Sep 25, 2025 |
| NRC Officer: | Ernest West |
| Last Updated: | Sep 25, 2025 |
| 57953 - NRC Website | |
Ucla with Agreement State | |
WEEKMONTHYEARENS 579532025-09-24T19:00:00024 September 2025 19:00:00
[Table view]Agreement State Medical Event ENS 450502009-05-06T07:00:0006 May 2009 07:00:00 Agreement State Agreement State Report- Missing Sealed Sources ENS 443212008-06-23T07:00:00023 June 2008 07:00:00 Agreement State Potential Underdose to Patient Undergoing Whole Body Radiation 2025-09-24T19:00:00 | |