ENS 48286

v t e ENS Event
04:00 Sep 6, 2012
Title	Agreement State Report - Yttrium-90 Microspheres Administered to the Wrong Treatment Site
Event Description	On September 6, 2012, the [Pennsylvania Department of Environmental Protection, Bureau of Radiation Protection (PADEPBRP)] Central Office received notification via a phone call about this medical event. The patient received an administration of approximately 1.4 millicuries (mCi) of Y-90 microspheres to the wrong treatment site. The intended treatment was to administer approximately 24 mCi to the left lobe of the liver through three different arteries. During the administration of one of the split doses, the Interventional Radiologist (IR) incorrectly positioned the catheter in the right hepatic artery. A portion of the one split dose was administered to the right lobe of the liver before the IR realized that the catheter was not in the correct artery. Cause of the event: Human Error. Actions: Both the referring physician and the patient have been notified of the medical event. The [PADEPBRP] plans to do a reactive inspection. 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 48286 +/-
Where
University Of Pittsburgh Pittsburgh, Pennsylvania (NRC Region 1)
License number:	PA-0190
Organization:	Pa Bureau Of Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+34.48 h1.437 days <br />0.205 weeks <br />0.0472 months <br />)
Opened:	Joseph Melnic 14:29 Sep 7, 2012
NRC Officer:	Pete Snyder
Last Updated:	Sep 7, 2012
48286 - NRC Website
v • d • e

v t e Emergency Notification System
University Of Pittsburgh with Agreement State
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