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. |
| 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 | |
University Of Pittsburgh Medical Center with Agreement State | |
WEEKMONTHYEARENS 448002008-12-04T05:00:0004 December 2008 05:00:00
[Table view]Agreement State Agreement State Report - Dose Administered to Patient Was Less than 50% of Prescribed Dose 2008-12-04T05:00:00 | |