ENS 44800

v t e ENS Event
05:00 Dec 4, 2008
Title	Agreement State Report - Dose Administered to Patient Was Less than 50% of Prescribed Dose
Event Description	The following information was obtained from the Commonwealth of Pennsylvania via email: Dose administered to patient was only 44% of the prescribed amount of Y90. Cause: the treatment catheter became occluded and prevented further delivery of the Y-90 microspheres to the patient. It is not known what caused the occlusion. A later radiation survey of the catheter indicated a relative increased amount of radioactivity within the last 2cm from the tip. The catheter will be sent to the manufacturer for further analysis. Effect to the Patient: None Notifications : The referring physician was verbally notified of the medical event by the Authorized User. The referring physician verbally notified the patient. Corrective Action: Equipment returned to manufacturer for repair or disposal. Dose given was 5.3 mCi of Y-90. Dose intended was 12.1 mCi. PA Reference Number: PA080033 A Medical Event may indicate potential problems in a medical facilities use of radioactive materials. It does not necessarily result in harm to the patient.

ENS 44800 +/-
Where
University Of Pittsburgh Medical Center Pittsburgh, Pennsylvania (NRC Region 1)
License number:	PA-0190
Organization:	Pa Bureau Of Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+1188.07 h49.503 days <br />7.072 weeks <br />1.627 months <br />)
Opened:	David Allard 17:04 Jan 22, 2009
NRC Officer:	Howie Crouch
Last Updated:	Jan 23, 2009
44800 - NRC Website
v • d • e

v t e Emergency Notification System
University Of Pittsburgh Medical Center with Agreement State
WEEKMONTHYEAR2008-12-04T05:00:00 [Table view]
[ENS list for University Of Pittsburgh Medical Center]

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