ENS 55376

v t e ENS Event
04:00 Jul 22, 2021
Title	Patient Under Dose
Event Description	The following was received via an email from the Pennsylvania Department of Environmental Protection (DEP) via email: On July 22, 2021 a patient was receiving a Lutetium-177 (Lutathera) treatment when technicians had difficulty establishing an IV injection site and flow. Several attempts were made, but ultimately they all failed. The prescribed dose was 200 milliCuries, but it is estimated that the patient received only 18 millicuries. No adverse effects to the patient are noted at this time and none are expected. The patient and prescribing physician have been informed. Preliminary cause is suspected to be poor venous access for patient as well as incorrect gauge needle used for patient access. The DEP will update this event as soon as more information is provided. The Department will perform a reactive inspection. Pennsylvania Event Report ID No: PA210008 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 55376 +/-
Where
Geisinger Health System Danville, Pennsylvania (NRC Region 1)
License number:	PA-0006
Organization:	Pa Bureau Of Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+33 h1.375 days <br />0.196 weeks <br />0.0452 months <br />)
Opened:	John Chippo 13:00 Jul 23, 2021
NRC Officer:	Lloyd Desotell
Last Updated:	Jul 23, 2021
55376 - NRC Website
v • d • e

v t e Emergency Notification System
Geisinger Health System with Agreement State
WEEKMONTHYEAR2023-01-11T05:00:00 [Table view]
[ENS list for Geisinger Health System]

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