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. |
| 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 | |
Cleveland Clinic Foundation with Agreement State | |
WEEKMONTHYEARENS 576312025-03-25T04:00:00025 March 2025 04:00:00
[Table view]Agreement State Medical Event ENS 551572021-03-26T18:00:00026 March 2021 18:00:00 Agreement State Medical Event Report - Underdosage ENS 536722018-10-16T04:00:00016 October 2018 04:00:00 Agreement State En Revision Imported Date 7/24/2019 ENS 498152014-01-24T05:00:00024 January 2014 05:00:00 Agreement State Agreement State Report - Medical Event Involving Unintended Dose ENS 470712011-07-12T15:00:00012 July 2011 15:00:00 Agreement State Agreement State Report - Patient Received Treatment to Incorrect Organ ENS 465722010-12-08T05:00:0008 December 2010 05:00:00 Agreement State Agreement State Report - Potential Underdose to Patient Due to Aborted Treatment ENS 463762010-10-29T04:00:00029 October 2010 04:00:00 Agreement State Agreement State - Dose Delivered to Wrong Organ ENS 462862010-09-27T04:00:00027 September 2010 04:00:00 Agreement State Ohio Agreement State Report - 95% Medical Underdosage Due to Equipment Failure ENS 443972008-08-07T18:00:0007 August 2008 18:00:00 Agreement State Agreement State Report - Underexposure During Hdr Medical Treatment Due to Equipment Malfunction ENS 405752004-03-04T21:00:0004 March 2004 21:00:00 Agreement State the Cleveland Clinic Foundation Administered an Underdose During a Therapeutic Treatment 2025-03-25T04:00:00 | |