ENS 49396

v t e ENS Event
04:00 Aug 15, 2013
Title	Agreement State Report - Medical Misadministration of Y-90
Event Description	The following information was received from the City of New York via email: Incident: Due to the technical difficulties, physician could not deliver the full prescribed dose of Y-90. Radiation Dose evaluation: As per physician's medical judgment, the dose given to the patient was adequate for the treatment of this volume and tumors within the region. Health effects: Patient will be followed up to determine if an appropriate therapeutic result is achieved. Corrective Actions: Administered radiological agent was Y-90 SIRTex. RSO and administering physician have come to the conclusion to wait until the vial and related accessories reach background [radiation levels] in order to investigate this matter. It is unknown whether this was a human error or manufacturer defect. As per facility's report, as a precautionary measure, derma bond will be applied to the v-vial before administration of the dose in order to prevent any possibility of leakage. The prescribed dose of Y-90 was 30 mCi; the delivered dose was 19.26 mCi. NYC Incident Report Identification Number: 75-2885-01 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 49396 +/-
Where
Montefiore Medical Center New York, New York (NRC Region 1)
License number:	NOT PROVIDED
Organization:	New York City Bureau Of Rad Health
Reporting

Agreement State
Time - Person (Reporting Time:+1115.62 h46.484 days <br />6.641 weeks <br />1.528 months <br />)
Opened:	Tobias Lickerman 15:37 Sep 30, 2013
NRC Officer:	Howie Crouch
Last Updated:	Sep 30, 2013
49396 - NRC Website
v • d • e

v t e Emergency Notification System
Montefiore Medical Center with Agreement State
WEEKMONTHYEAR2014-02-27T04:00:00 [Table view]
[ENS list for Montefiore Medical Center]

Navigation menu