The following information was received from the State of
Oregon via email:
[The licensee reported] a misadministration on Monday, August 13, 2012, during a treatment with [Y-90] TheraSpheres. The misadministration was due to a malfunction of the syringe plunger of the delivery device, and is the first time that this problem has occurred at Oregon Health & Science University.
This was a two-vial treatment, and the malfunction occurred with the first delivery set. (The activity from the second vial, and with a new delivery set, was administered with no difficulty. Delivery sets are single-use.). The nurse who was setting up the system, and who routinely sets up the systems, noticed a stiffness when she was snapping the plunger into position through the vial septum. She was not able to retract the needles (the plunger is designed not to be removable), and it appeared to be placed properly.
The physician was informed of the 'stickiness'. The patient's catheter was correctly hooked up to the delivery device, and the catheter in the patient was in the desired position. As soon as the administration was started, blood backed up into the catheter, which was unusual. Normal attempts to administer the activity by pushing saline into the vial resulted in fluid running into the over-pressure vial. The treating physician ended the attempt to deliver the activity, and the system was removed in the normal way by placing the used items in the waste container.
The second delivery set and the second dose vial were placed in position, the patient catheter hooked up, and the delivery of the activity went smoothly.
The patient was notified of the problem and of the possibility of a retreat. The Oregon Department of Health Radiation Protection are waiting for the Nordion technical adviser to call mid-day today.
The Y-90 TheraSphere treatment consisted of:
Vial 1 - Script 66 Gray, Administered 12 Gray, 81.8 % Error of 54 Gray
Vial 2 - Script 55 Gray, Administered 50.2 Gray, 8.7 % Error of 4.8 Gray
Treatment Total - Script 121 Gray, Administered 62.2 Gray, 48.5 % Error of 58.8 Gray
Oregon Incident # - 12-0031
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.