ENS Event | |
|---|---|
07:00 Mar 5, 2008 | |
| Title | Agreement State Report - Misadministration of Y-90 Microspheres |
| Event Description | The State provided the following information via facsimile:
A medical licensee notified the Department of a misadministration during a Y-90 microsphere procedure, The problem was identified at the conclusion of the procedure when staff noted that 50% of the Y-90 microspheres were still in the application kit, resulting in a 50% underdose to the patient. The licensee's medical physicist, who is investigating the incident, was unsure if the problem was caused by a faulty injection valve or human error (e.g.. The valve was turned to the wrong position during the procedure). The licensee is Skyridge Medical Center Denver, CO, License 1053-01. No other details are available at this time. The Department has initiated an investigation of this incident.
The NRC has reviewed this event and determined it to be a reportable medical event. 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 | |
|---|---|
| Skyridge Medical Center Denver, Colorado (NRC Region 4) | |
| License number: | 1053-01 |
| Organization: | Colorado Dept Of Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+9.23 h0.385 days <br />0.0549 weeks <br />0.0126 months <br />) | |
| Opened: | Ed Stroud 16:14 Mar 5, 2008 |
| NRC Officer: | Joe O'Hara |
| Last Updated: | Mar 7, 2008 |
| 44033 - NRC Website | |
Skyridge Medical Center with Agreement State | |
WEEKMONTHYEARENS 440332008-03-05T07:00:0005 March 2008 07:00:00
[Table view]Agreement State Agreement State Report - Misadministration of Y-90 Microspheres 2008-03-05T07:00:00 | |