ENS Event | |
|---|---|
17:40 Feb 20, 2008 | |
| Title | |
| Event Description | The licensee reported that a patient being treated for liver cancer received approximately half of the prescribed dose of Y-90 microspheres. The licensee calculates the patient received 16 Grays instead of the prescribed 38 Grays.
The treatment is performed in three flushes. The patient receives 50% of the medication in the first flush and the remaining 50% in the second flush. The third flush is performed to ensure all the prescribed medication has been applied to the patient. In this case, the patient received the first flush but the second flush wouldn't go through the line. The licensee is investigating a problem with the three-way valve used in the treatment or potentially a crimp in the line which caused a blockage. Both the patient and prescribing physician are aware of this problem, and the other half of the patient's therapy is planned for a future time period. 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 | |
|---|---|
| Vcu Medical Center Richmond, Virginia (NRC Region 1) | |
| License number: | 45-00048-17 |
| Organization: | Virginia Commonwealth University |
| Reporting | |
| 10 CFR 35.3045(a)(1) | |
| Time - Person (Reporting Time:+19.7 h0.821 days <br />0.117 weeks <br />0.027 months <br />) | |
| Opened: | Dean Broga 13:22 Feb 21, 2008 |
| NRC Officer: | Joe O'Hara |
| Last Updated: | Feb 21, 2008 |
| 43999 - NRC Website | |
Vcu Medical Center with 10 CFR 35.3045(a)(1) | |
WEEKMONTHYEARENS 439992008-02-20T17:40:00020 February 2008 17:40:00
[Table view]10 CFR 35.3045(a)(1) Potential Medical Event - Underdose of Y-90 Microspheres 2008-02-20T17:40:00 | |