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.
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). |
| 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 | |
Charlotte-Mecklenburg Hospital Authority with Agreement State | |
WEEKMONTHYEARENS 553782021-06-30T04:00:00030 June 2021 04:00:00
[Table view]Agreement State Lost I-125 Brachytherapy Seed ENS 448232009-01-27T05:00:00027 January 2009 05:00:00 Agreement State Agreement State Report - Medical Event 2021-06-30T04:00:00 | |