ENS 43336

v t e ENS Event
17:39 Feb 2, 2007
Title	Agreement State Report - Medical Misadministration
Event Description	The State provided the following information via facsimile: Patient was scheduled for administration of 30 millicuries of 90Y [Yttrium-90] microspheres. The delivery catheter developed a leak during the administration. Leakage was mostly contained within the Plexiglas box containing the vial of microspheres. There was very minimal contamination outside of the box. Licensee performed bremsstrahlung measurements of the patient and the Plexiglas box. Based on differences, the administered dose was determined to be only 66% of the prescribed dose. Licensee noted that this was the first of a two part administration of the microspheres and the dose at the next treatment will be adjusted to compensate for the 'missing' activity. The device manufacturer (Sirtex) traced the leaky units to one operator who had deviated from the normal assembly procedure. Sirtex destroyed the remainder of that lot number and replaced them with a new, tested lot. NC Event Report ID number: NC-07-02 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. * * UPDATE FROM C. FLANNERY TO P. SNYDER AT 1436 ON 5/02/07 * * * The NRC's medical events review committee has determined that this report is a medical event. Notified R1DO (Holody) and FSME (Morell) via e-mail.

ENS 43336 +/-
Where
Carolinas Medical Center Charlotte, North Carolina (NRC Region 1)
License number:	060-0014-3
Organization:	Nc Div Of Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+2129 h88.708 days <br />12.673 weeks <br />2.916 months <br />)
Opened:	J. Marion Eaddy Iii 09:39 May 2, 2007
NRC Officer:	Jason Kozal
Last Updated:	May 2, 2007
43336 - NRC Website
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v t e Emergency Notification System
Carolinas Medical Center with Agreement State
WEEKMONTHYEAR2008-03-14T04:00:00 [Table view]
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