ENS Event | |
|---|---|
04:00 Jan 20, 2010 | |
| Title | Medical Treatment Terminated Prior to Administering Full Dose |
| Event Description | A patient's liver was being treated using SIR-Spheres through a catheter. During the administration of the Y-90 SIR-Spheres, the physician believed that there was leakage around the stopper and halted the medical procedure with only 21.9 mCi administered instead of the complete dose of 30.7 mCi i.e. 71% of the prescribed dose. The manufacturer was notified of the potential manufacturing defect and the hospital was directed to ship the delivery apparatus (as is) back to the manufacturer after the Y-90 had decayed. The equipment was returned to the manufacturer on April 5, 2010 and a report was received from the manufacturer on June 21, 2010. "The manufacturer noted that there was leaking but could not conclude that it was a manufacturer defect or if the physician applied too much pressure to the V-vial during the procedure." The patient was notified of the dose received.
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. |
| Where | |
|---|---|
| West Virginia University Hospital Morgantown, West Virginia (NRC Region 1) | |
| License number: | 47-23066-02 |
| Organization: | West Virginia University Hospital |
| Reporting | |
| 10 CFR 35.3045(a)(1) | |
| Time - Person (Reporting Time:+4040.62 h168.359 days <br />24.051 weeks <br />5.535 months <br />) | |
| Opened: | Nasser Razmianfar 11:37 Jul 7, 2010 |
| NRC Officer: | Mark Abramovitz |
| Last Updated: | Jul 7, 2010 |
| 46074 - NRC Website
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West Virginia University Hospital with 10 CFR 35.3045(a)(1) | |
WEEKMONTHYEARENS 566862023-08-17T04:00:00017 August 2023 04:00:00
[Table view]10 CFR 35.3045(a)(1) Medical Event - Patient Underdose ENS 529492017-09-05T20:30:0005 September 2017 20:30:00 10 CFR 35.3045(a)(1) Brachytherapy Treatment Delivered Dose Less than Prescribed Dose ENS 460742010-01-20T04:00:00020 January 2010 04:00:00 10 CFR 35.3045(a)(1) Medical Treatment Terminated Prior to Administering Full Dose 2023-08-17T04:00:00 | |