ENS Event | |
|---|---|
04:00 May 9, 2013 | |
| Title | Medical Event Involving Dose to the Wrong Organ |
| Event Description | The following information was obtained from the State of Ohio via email:
At 1000 [EDT] on Sept 20, 2013 the Cleveland Clinic Foundation (CCF) RSO called the Ohio Department of Health (ODH) Bureau of Radiation Protection to report the determination of a medical event based on the back calculations from a symptomatic patient that had received a Y-90 microsphere treatment on May 9, 2013. The patient received a treatment of Y-90 SIR-Spheres to both the left and right lobes of the liver. The vessel to the stomach area was coiled to prevent shunting. At the time of the treatment, the patient complained of some abdominal pain. The post-treatment scan was inconclusive regarding the shunting to the stomach area. The AU [authorized user] and interventional radiologist concluded that a shunt was unlikely. The patient continued to complain of stomach pain and returned to the CCF on Sept 5, 2013 for an endoscopy. The endoscopy revealed ulcers in the potentially affected areas. After additional review of the post-treatment scan by the licensee, it was not abundantly apparent, but possible, that shunting did occur. Based on the assumption that shunting did occur, the licensee determined that the gastric antrum, an unintended treatment area, received a dose of 62 Gy. The ODH Bureau of Radiation will be conducting an onsite investigation. This incident was assigned ODH incident report number 2013-011. NMED Item Number: OH130014 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 | |
|---|---|
| Cleveland Clinic Cleveland, Ohio (NRC Region 3) | |
| License number: | 02110180013 |
| Organization: | Ohio Bureau Of Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+3223.97 h134.332 days <br />19.19 weeks <br />4.416 months <br />) | |
| Opened: | Karl Von Ahn 11:58 Sep 20, 2013 |
| NRC Officer: | Howie Crouch |
| Last Updated: | Sep 20, 2013 |
| 49366 - NRC Website | |
Cleveland Clinic with Agreement State | |
WEEKMONTHYEARENS 567542023-09-20T04:00:00020 September 2023 04:00:00
[Table view]Agreement State Missing I-125 Seed ENS 493662013-05-09T04:00:0009 May 2013 04:00:00 Agreement State Medical Event Involving Dose to the Wrong Organ 2023-09-20T04:00:00 | |