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. |
| 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 | |
Montefiore Medical Center with Agreement State | |
WEEKMONTHYEARENS 498872014-02-27T04:00:00027 February 2014 04:00:00
[Table view]Agreement State Agreement State Report - Underdose of Y-90 Administration to Liver ENS 493962013-08-15T04:00:00015 August 2013 04:00:00 Agreement State Agreement State Report - Medical Misadministration of Y-90 ENS 469622006-09-22T04:00:00022 September 2006 04:00:00 Agreement State Patient Received Radiation Therapy and Later Determined to Be Pregnant 2014-02-27T04:00:00 | |