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.
|
| 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 | |
Carolinas Medical Center with Agreement State | |
WEEKMONTHYEARENS 440692008-03-14T04:00:00014 March 2008 04:00:00
[Table view]Agreement State Agreement State - Leaking Iodine- 125 Prostate Seeds ENS 437262007-10-12T04:00:00012 October 2007 04:00:00 Agreement State Agreement State Report - Leaking I-125 Prostate Brachytherapy Seed ENS 433362007-02-02T17:39:0002 February 2007 17:39:00 Agreement State Agreement State Report - Medical Misadministration 2008-03-14T04:00:00 | |