|AGREEMENT STATE REPORT - MEDICAL EVENT- ELUATE EXCEEDED BREAKTHROUGH LIMITS ON RUBIDIUM - 82 GENERATOR
The following was received from the State of Kentucky via fax.
"On Thursday, March 21, 2019, a technologist inadvertently used Ringer's saline as the eluate on a Bracco Rb-82 generator. On March 21, 2019, four (4) patients were imaged using the Rb-82 generator at 0852/0902, 1037/1049, 1143/1156, and 1335/1347 EDT (two infusions per patient). On March 21, 2019, a technologist notified Bracco that their eluate volumes for each patient were decreasing slightly, while the overall activity of each infusion remained the same, this was the inverse of what they normally saw. On the morning of March 22, 2019, routine quality control was performed at 0730 EDT and it was found that the Sr-82 breakthrough measured 18.6 microCuries and the generator expiry limit was exceeded. The technologist inspected the unit's tubing and settings, but found nothing out of the ordinary. The Bracco representative returned the previous day's call and said to check the saline attached to the machine. It was discovered that Ringer's saline had been used. The RSO [Radiation Safety Officer] was notified and the hospital was instructed to discontinue use."
Kentucky Event Report ID No.: KY190003
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.