ENS 46791

v t e ENS Event
14:45 Apr 27, 2011
Title	Patient Received Less than Prescribed Dose Due to an Occlusion in the Delivery Catheter
Event Description	A patient received 14.8 Gray rather than the 63 Gray prescribed treatment to the upper portion of the liver using SIRSpheres manufactured by Sirtex. Only 0.7 GBq of the 3 GBq Y-90 microspheres were delivered to the treatment site due to an occlusion in the micro catheter. The treating physician terminated the dose administration after encountering difficulty in "pushing" the syringe contents through the micro catheter. While removing the catheter a small release of microspheres occurred due to the trapped pressure. The spill was contained and immediately cleaned up. The Hospital contacted the manufacturer and will return the dose unit for analysis. Both the patient and the referring physician have been informed. There was no adverse impact to the patient who has been rescheduled for a compensatory dose next week. 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 46791 +/-
Where
Beaumont Hospitals Royal Oak, Michigan (NRC Region 3)
License number:	21-01333-01
Organization:	Beaumont Hospitals
Reporting

10 CFR 35.3045(a)(1)
Time - Person (Reporting Time:+1.33 h0.0554 days <br />0.00792 weeks <br />0.00182 months <br />)
Opened:	Sheryl Schultz 16:05 Apr 27, 2011
NRC Officer:	Steve Sandin
Last Updated:	Apr 27, 2011
46791 - NRC Website
v • d • e

v t e Emergency Notification System
Beaumont Hospitals with 10 CFR 35.3045(a)(1)
WEEKMONTHYEAR2011-04-27T14:45:00 [Table view]
[ENS list for Beaumont Hospitals]

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