ENS 46376

v t e ENS Event
04:00 Oct 29, 2010
Title	Agreement State - Dose Delivered to Wrong Organ
Event Description	The following was received from the state of Ohio via email: Approximately three (3) weeks prior to therapy, the patient was scanned for extra hepatic shunting through injection of Tc-99m MAA into the hepatic artery per protocol. No shunting to the duodenum was identified. On Tuesday, October 26, 2010, at approximately 1455 hours0.0168 days <br />0.404 hours <br />0.00241 weeks <br />5.536275e-4 months <br />, the patient was treated with 3.959 GBq Y-90 TheraSphere microspheres per protocol. A Interventional Radiologist properly placed catheter, and confirmed by second Interventionist Radiologist. On Tuesday, October 26, 2010, at approximately 1930 hours0.0223 days <br />0.536 hours <br />0.00319 weeks <br />7.34365e-4 months <br />, a post-procedure scan identified significant activity in the duodenum. Initial estimate indicates dose to duodenum approximately 90 Gy (90 Sv). Patient has been hospitalized at Cleveland Clinic for observation and possible intervention as a result of dose to the duodenum. [The] patient has been notified. [The] referring physician has been notified. [A] literature search indicates patient may have developed vascularization post-scan, pre-treatment. Ohio Report #: OH 2010-060 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.

ENS 46376 +/-
Where
Cleveland Clinic Foundation Cleveland, Ohio (NRC Region 3)
License number:	02110180013
Organization:	Ohio Bureau Of Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+6.23 h0.26 days <br />0.0371 weeks <br />0.00853 months <br />)
Opened:	Michael Snee 10:14 Oct 29, 2010
NRC Officer:	Charles Teal
Last Updated:	Oct 29, 2010
46376 - NRC Website
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v t e Emergency Notification System
Cleveland Clinic Foundation with Agreement State
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