ENS Event | |
|---|---|
23:00 Sep 9, 2011 | |
| Title | Agreement State Report Involving a Less than Prescribed Dose Administration |
| Event Description | The following information was received from the State of Texas via email:
On September 13, 2011, the Agency was notified by the licensee that it had determined that a medical event had occurred at its facility. The licensee reported that on Friday, September 9, 2011, a patient had undergone a therapy procedure at approximately 3:00 p.m. which involved insertion of Yttrium-90 TheraSpheres into the liver. The patient's prescribed dose was to be 80 gray. Following the procedure, the technician took measurements, as part of the standard operating procedures, of the vial and other items associated with the treatment. The technician found that the dose rate was higher than would be expected if all of the contents of the vial had been delivered. The technician notified the medical physicist and they discussed the measurements. At approximately 6:00 p.m. they determined that an underdose had most likely occurred, but they were not yet sure it was a medical event. On Monday, September 12th, evaluation and measurements were conducted on the vial and dose calculations were completed. On Monday afternoon, it was determined that the patient had received a dose of 49 gray (22.3 millicuries administered), which is 39% less than the prescribed dose of 80 gray (37 millicuries). A meeting was arranged with the facility's Radiation Safety Officer on Tuesday, September 13th, at which time he was advised of the findings. Initial investigation by the licensee indicated some type of failure of the septum on the TheraSphere vial had occurred. The licensee will complete their investigation and submit a written report. An update to this report will be provided when new information is received. Texas Incident No.: I-8883 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 | |
|---|---|
| Md Anderson Cancer Center Houston, Texas (NRC Region 4) | |
| License number: | L00466 |
| Organization: | Texas Department Of Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+112.05 h4.669 days <br />0.667 weeks <br />0.153 months <br />) | |
| Opened: | Karen Blanchard 15:03 Sep 14, 2011 |
| NRC Officer: | Steve Sandin |
| Last Updated: | Sep 14, 2011 |
| 47266 - NRC Website | |
Md Anderson Cancer Center with Agreement State | |
WEEKMONTHYEARENS 473402011-10-12T19:30:00012 October 2011 19:30:00
[Table view]Agreement State Agreement State Report - Malfunction of Irradiator Source Drive Mechanism ENS 472662011-09-09T23:00:0009 September 2011 23:00:00 Agreement State Agreement State Report Involving a Less than Prescribed Dose Administration ENS 444602008-08-15T05:00:00015 August 2008 05:00:00 Agreement State Agreement State Report - Irradiator Crank Mechanism Failure 2011-09-09T23:00:00 | |