ENS 46683
ENS Event | |
|---|---|
05:00 Mar 17, 2011 | |
| Title | Agreement State Report - Yttrium-90 Microspsheres Administered at 150% of Prescribed Dose |
| Event Description | A medical event took place at Abbott-Northwestern Hospital involving a Yttrium-90 (Y-90) SIR microsphere therapy patient treated on 3/17/2011. It was discovered on 3/18/11, by the radiation oncologist covering the SIRS procedure from the day before, that the delivered amount of Y-90 SIRS wasn't 105% above the prescribed dose as intended, but actually 150% above the prescribed dose. She then brought this error to the attention of the lead medical physicist who was the attending medical physicist responsible for this treatment delivery, for further clarification. Upon investigation, it was deduced that the medical physicist had not read the patient's SIRS therapy (utilizing Y-90 radioactive isotope) written directive prescription correctly. A higher than intended dosage was administered to the patient (1.66 GBq). The correct dosage that was intended to be administered per the written directive was 1.11 GBq. After calculation was made after the incident it was determined that the intended dose to the liver was 30.72 Gy and the actual dose to the liver was 45.93 Gy.
Contributing factors to the above error identified by the licensee are as follows: 1. The amount of information presented in the SIRS written directive and the prescribed amount of isotope is hard to discern and is not set apart from all the other numbers presented. 2. The prescribed activity is manually transferred to a secondary worksheet used in Nuclear Medicine to draw the dose to be administered and this secondary activity worksheet is not verified by a secondary party. The licensee stated that to prevent such an event from occurring in the future, the SIRS written directive document will be modified to display the prescribed activity more predominantly on the form as well as a space for initializing by a secondary party that the prescribed dose has been transferred/entered properly on the secondary activity worksheet that is used in Nuclear Medicine to draw the dose to be administered. The referring physicians as well as the patient have been or are in the process of being notified of this event. According to the licensee's Radiation Oncologist and Interventional Radiologist that were asked to consult, this higher dose would slightly increase the patient's risk of radiation-induced liver disease. The patient, as is standard for all SIRS (Y-90) patients, will receive liver function follow-up testing to track her status. 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 | |
|---|---|
| Abbott Northwestern Hospital Minneapolis, Minnesota (NRC Region 3) | |
| License number: | 1007-209-27 |
| Organization: | Minnesota Department Of Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+35.22 h1.468 days <br />0.21 weeks <br />0.0482 months <br />) | |
| Opened: | Bryce Armstrong 16:13 Mar 18, 2011 |
| NRC Officer: | Donald Norwood |
| Last Updated: | Mar 18, 2011 |
| 46683 - NRC Website | |
Abbott Northwestern Hospital with Agreement State | |
WEEKMONTHYEARENS 556572019-07-26T06:00:00026 July 2019 06:00:00
[Table view]Agreement State Lost Brachytherapy Seed ENS 511002015-05-29T15:30:00029 May 2015 15:30:00 Agreement State Agreement State Report - Medical Treatment to Incorrect Lobe of the Liver ENS 493312013-09-06T05:00:0006 September 2013 05:00:00 Agreement State Agreement State Report - Dose Delivered to Wrong Site ENS 476482012-02-02T06:00:0002 February 2012 06:00:00 Agreement State Agreement State Report - Y-90 Dosage to Unintended Areas ENS 466832011-03-17T05:00:00017 March 2011 05:00:00 Agreement State Agreement State Report - Yttrium-90 Microspsheres Administered at 150% of Prescribed Dose 2019-07-26T06:00:00 | |