ENS 54231

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v t e ENS Event
05:00 Jul 30, 2019
Title	Agreement State Report - Incorrect Dosage Administered
Event Description	The following was received via email: On August 19, 2019, the Agency [Texas Department of State Health Services] was notified by the licensee's radiation safety officer (RSO) that a medical event had occurred. The event occurred on a patient who was prescribed to receive four treatments of lutetium-177 at 200 milliCuries each. After the third treatment, the physician was supposed to change the dose of the fourth and final dose to 100 milliCuries. The radiopharmaceutical was ordered, and the dose was administered. The RSO stated that during the review of the patient's treatment, they found the pharmacy had sent a unit dose of 200 milliCuries instead of the requested 100 milliCuries. The RSO stated both the prescribing physician and the patient were notified of the error. No adverse effects are expected on the patient. The Agency has requested additional information on this event. Additional information will be provided as it is received in accordance with SA-300. * * UPDATE ON 8/20/19 AT 1133 EDT FROM ART TUCKER TO BETHANY CECERE * * * On August 20, 2019, the licensee contacted the Agency and stated the treatment site was the mid-gut. The treatment was conducted on July 30, 2019. The error was discovered the day of the event. Additional information will be provided as it is received in accordance with SA-300. 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.

ENS 54231 +/-
Where
Texas Oncology Pa Dallas, Texas (NRC Region 4)
License number:	L04878
Organization:	Texas Dept Of State Health Services
Reporting

Agreement State
Time - Person (Reporting Time:+510.32 h21.263 days <br />3.038 weeks <br />0.699 months <br />)
Opened:	Art Tucker 11:19 Aug 20, 2019
NRC Officer:	Bethany Cecere
Last Updated:	Aug 20, 2019
54231 - NRC Website
v • d • e

v t e Emergency Notification System
Texas Oncology Pa with Agreement State
WEEKMONTHYEAR2019-07-30T05:00:00 [Table view]
[ENS list for Texas Oncology Pa]

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ENS Notification