ENS 44823

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v t e ENS Event
05:00 Jan 27, 2009
Title	Agreement State Report - Medical Event
Event Description	The following information was obtained from the State of North Carolina via facsimile: On January 27, 2009, a Therasphere (Y-90 microsphere) procedure was scheduled for a patient in Room 4, Special Procedures. The treatment was planned to deliver 110 Gy to the left lobe of the liver. The delivery apparatus was assembled according to manufacturer instructions, without incident. The treatment was initiated. During the first infusion, the Authorized User noticed fluid leakage at the outlet flow line and needle insertion at the source vial. The RSO was contacted. An attempt was made to continue the infusion. The liquid continued to leak at the outlet flow line and needle junction. No additional radioactivity was delivered to the patient. The procedure was terminated. Post procedure survey readings of the source vial indicated that approximately 65% of the intended radioactivity was delivered to the patient. This resulted in a dose of 70 Gy delivered to the left lobe of the liver. The Authorized User indicated that no adverse clinical symptoms are expected. This was the second treatment for this patient. The manufacturer (MDS Nordion) was notified of the device problem on 01/28/09. All liquid and contamination was contained by Radiation Safety personnel. 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. * * UPDATE AT 1425 ON 2/06/09 FROM ALBRIGHT TO KLCO* * * Notified that the event is documented by the North Carolina Radioactive Materials Branch as incident NC-09-11. Notified the R1DO (Gray) and FSME (McIntosh).

ENS 44823 +/-
Where
Charlotte-Mecklenburg Hospital Authority Charlotte, North Carolina (NRC Region 1)
License number:	060-0014-3
Organization:	Nc Div Of Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+151.42 h6.309 days <br />0.901 weeks <br />0.207 months <br />)
Opened:	Sharn Jeffries 12:25 Feb 2, 2009
NRC Officer:	Howie Crouch
Last Updated:	Feb 6, 2009
44823 - NRC Website
v • d • e

v t e Emergency Notification System
Charlotte-Mecklenburg Hospital Authority with Agreement State
WEEKMONTHYEAR2021-06-30T04:00:00 [Table view]
[ENS list for Charlotte-Mecklenburg Hospital Authority]

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