ENS 47648
ENS Event | |
|---|---|
06:00 Feb 2, 2012 | |
| Title | Agreement State Report - Y-90 Dosage to Unintended Areas |
| Event Description | The following was received from the State of Minnesota via email:
On February 3, 2012, Minnesota Department of Health Radioactive Materials unit received notice that a licensee had a medical event during a Y-90 SIRS spheres procedure. After infusion of radioactive Y-90, in the form of SIRS spheres for treatment of the liver, it was discovered, by follow-up radionuclide scanning, that some of the material was not in the liver as intended. Material appeared in vessels involving the spleen and digestive track instead. The amount has not been determined at this time, but it is possible that this may cause unintended, permanent, functional damage. The interventional radiologist involved with the treatment has ensured us that the patient will be notified along with the referring physician today. It is likely that some form of medical intervention will be taken. On February 6, 2012, the Radioactive Material supervisor and inspector met with the licensee to discuss the medical event. The Y-90 SIRS spheres procedure went accordingly to plan; it was discovered on the follow-up SPECT imaging that an estimated 10%-15% of the material was in the spleen, gastric fundus, and duodenum. The patient and ordering physician had been notified. The intended area for the material was the liver with an activity of 50 GBq. The three unattended areas that were discovered with material were estimated to receive a dose of 0. The Medical Physicist gave us the best preliminary dose estimates based on CT images obtained the day after the procedure at which the stomach and duodenum were different in shape. Early dose estimates for each region (spleen, gastric fundus, and duodenum) estimates approximately 30 Gy for each area. The Minnesota Department of Health Radioactive Materials unit will continue communication and obtain the final estimation for dose estimates.
The following information was received by email: Abbott Northwestern has submitted final best estimates pertaining to the medical event of Y-90 SIRS Spheres that occurred on Thursday, February 2, 2012. The final administered activity after accounting for loss in the delivery system was 1.53 GBq, original activity was 1.55 GBq. Estimates of radioactivity, organ volumes and radiation dose were derived by evaluation of SPECT CT images. The final best estimates are determined as follows: Organ / tissue Fraction of activity Volume (cc) Average dose (Gy) Liver 0.839 1209 53 Fundus of stomach 0.058 101 44 Spleen 0.093 200 35 Portion of duodenum 0.010 41 35 These estimates have a relatively high uncertainty (at least 20%) and local concentrations and doses may be significantly higher. Maximum concentrations per pixel in the SPECT images were as much as 50% higher than the average concentration. Notified the R3DO (Passehl) and FSME EO (McIntosh).
Event title edited to better characterize the event. Notified R3DO (Passehl) and FSME_Events Resource both via E-mail. 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: | 1007-211-27 |
| Organization: | Minnesota Department Of Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+154 h6.417 days <br />0.917 weeks <br />0.211 months <br />) | |
| Opened: | Teresa Purrington 16:00 Feb 8, 2012 |
| NRC Officer: | Charles Teal |
| Last Updated: | Jun 8, 2012 |
| 47648 - 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 | |