The following report was received via email:
Event type: Medical Event involving the administration of yttrium-90 (Y-90) Sir-Spheres.
Notifications: On October 17, 2013 the licensee informed the Department's Central Office of the Medical Event. The event is reportable within 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> per 10 CFR 35.3045(a)(1)(i). Appropriate reporting to the referring physician and the patient is currently underway.
Event Description: The patient was scheduled to receive two split doses on May 7, 2013. The plan was to treat the left hepatic artery segment 2 and 3 with 11.9 mCi (0.44 GBq) and the left hepatic artery segment 4 with 11.9 mCi (0.44 GBq). The unit doses were assayed separately and were found to be within 10% of the prescribed doses. After the doses were assayed, the exposure rate around the jar was measured and documented. After the procedure was completed, the tubing, V-Vial, and the jar were collected and then measured to calculate the residual activity using the same procedure and geometry used during the pre-dose measurements as per procedure. The post treatment measurements and calculations revealed the following delivered doses. The left hepatic artery segment 2 and 3 branches received 9.2 mCi and the left hepatic artery segment 4 branch received 8.92 mCi. This resulted in under-dosing of 22.48% and 30.03% respectively.
CAUSE OF THE EVENT: Occlusion of SirSpheres in the delivery system. The post treatment measurements were high which indicated that there were some spheres in the tubing or the V-Vial. When the jar was opened, it was found that the three-way stop cock contained some of the activity.
ACTIONS: A new dose work sheet has been built in as a warning to remind the licensee to notify the regulatory agency should the dose variance exceed 20%.
Media attention: None at this time.
Pennsylvania Event Report Number - PA130055
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.