ENS 44335

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v t e ENS Event
17:04 Jul 2, 2008
Title	Agreement State Report - Less than 10% of Prescribed Dose Delivered
Event Description	A medical event occurred at 12:04 pm on July 2, 2008. The licensee is Baylor University Medical Center, License Number L01290. The unsealed source is Y-90 Therasphere microspheres for treatment of liver cancer. The prescribed dose is 100 Gray, and the prescribed dose range is from 95 Gray to 105 Gray. The activity of the Y-90 Therasphere microspheres was verified at 9:13 am - with 13.4 mCi in the vial - using the dose calibrator as per the manufacturer instructions. However when the dose was delivered the 3 way stop-cock was set erroneously and almost the entire dose was collected in the vent vial. Attempts to recover and deliver the misdirected dose was very limited. Post-administration, the residual activity in the original dose vial, the vent vial, and contaminated effects (catheter line, tubing, needles, towels, gauze pads, etc) totaled 12.046 mCi normalized to the 9:13 am verification time. Therefore, the estimated administered activity was approximately 1.3 mCi, administered on 2-July-2008 at 12:04 pm. This translates to approximately 8.7 Gray delivered to the treatment site (Liver Tumor). Essentially only 8.7% of the prescribed dose was delivered. The licensee is continuing the investigation. Texas event report I-8522 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.

ENS 44335 +/-
Where
Baylor Medical Center Waco, Texas (NRC Region 4)
License number:	L01290
Organization:	Texas Department Of Health
Reporting

Agreement State
Time - Person (Reporting Time:+21.12 h0.88 days <br />0.126 weeks <br />0.0289 months <br />)
Opened:	Ray Jisha 14:11 Jul 3, 2008
NRC Officer:	Mark Abramovitz
Last Updated:	Jul 3, 2008
44335 - NRC Website
v • d • e

v t e Emergency Notification System
Baylor Medical Center with Agreement State
WEEKMONTHYEAR2008-07-02T17:04:00 [Table view]
[ENS list for Baylor Medical Center]

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