ENS 47071
ENS Event | |
|---|---|
15:00 Jul 12, 2011 | |
| Title | Agreement State Report - Patient Received Treatment to Incorrect Organ |
| Event Description | Approximately four (4) weeks prior to the therapy, patient was scanned for extrahepatic shunting through injection of 99mTc MAA into the hepatic artery per protocol. No shunting to the duodenum was identified.
On Tuesday July 12, 2011, at 11:00 AM the patient was treated with 0.977 GBq of 90Y TheraSphere per protocol. Interventional Radiologist properly placed catheter. A second interventional Radiologist confirmed the catheter placement. On Tuesday July 12, 2011 at 6 PM, post procedure scan identified significant activity in the duodenum. Initial estimate indicates 0.117 GBq had shunted into the duodenum approximately 12% of the administered activity. An initial estimate indicates dose to duodenum is approximately 110 Gy. The asymptomatic patient was discharged with follow up contacts for possible intervention as a result of the dose to the duodenum. Patient has been notified. Referring physician has been notified. Literature search indicates patient may have developed vascularization post-scan, pretreatment. An inspector from the Department [Ohio Bureau of Radiation Protection] will conduct an inspection the week of July 25, 2011." Ohio Event Report Number: 2011-014 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.
Based on further review by the licensee, the patient's organ in question did not receive the above referenced dose. Notified the R3DO(Duncan) and FSME (Zelac). |
| 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:+163.08 h6.795 days <br />0.971 weeks <br />0.223 months <br />) | |
| Opened: | Mark Light 10:05 Jul 19, 2011 |
| NRC Officer: | John Knoke |
| Last Updated: | Jul 19, 2011 |
| 47071 - NRC Website | |
Cleveland Clinic Foundation with Agreement State | |
WEEKMONTHYEARENS 551572021-03-26T18:00:00026 March 2021 18:00:00
[Table view]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 2021-03-26T18:00:00 | |