ENS Event | |
|---|---|
18:50 Nov 14, 2013 | |
| Title | Y-90 Microshpere Dose Less than Prescribed |
| Event Description | On the afternoon of 11/14/2013, a patient was scheduled for a Y-90 microsphere radioembolization treatment at Indiana University Medical Center under NRC License 13-02752-03. The treatment consisted of two separate doses of Y-90 for which two separate written directives were prepared. Segment 4 of the patient's liver was prescribed a dosage of 27.0 mCi, and the right lobe of the liver was prescribed a dosage of 88.0 mCi. At 13:50 on 11/14/2013, following measurement of the remaining activity after injection of the Y-90 microspheres, it was determined that a dose of 19.5 mCi was delivered to segment 4 (72.2% of the intended dose). Shortly thereafter, at 14:06, a dose of 87.5 mCi of Y-90 was delivered to the right lobe (99.4% of the intended dose).
Both procedures appeared to proceed in accordance with standard operating procedures, and no abnormalities were identified during the procedure by the Interventional Radiology Physician or the Health Physicist supporting the procedure. Following the procedure, personnel and area surveys were performed using an SE International GM meter and no contamination of personnel, the room or equipment was identified. The container holding residual activity from the segment 4 treatment has been set aside for decay and further analysis. As the activity delivered to segment 4 of the liver meets the criteria in 10 CFR 35.3045(a)(1) and 10 CFR 35.3045(a)(1)(i), a report to the NRC Operations Center shall be made in accordance with 10 CFR 35.3045(c). The attending physician and patient will be contacted in accordance with 10 CFR 35.3045(e). 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 | |
|---|---|
| Indiana University Medical Center Indianapolis, Indiana (NRC Region 3) | |
| License number: | 13-02752-03 |
| Organization: | Indiana University Medical Center |
| Reporting | |
| 10 CFR 35.3045(a)(1) | |
| Time - Person (Reporting Time:+18.62 h0.776 days <br />0.111 weeks <br />0.0255 months <br />) | |
| Opened: | Mack Richards 13:27 Nov 15, 2013 |
| NRC Officer: | Bill Huffman |
| Last Updated: | Nov 15, 2013 |
| 49542 - NRC Website | |
Indiana University Medical Center with 10 CFR 35.3045(a)(1) | |
WEEKMONTHYEARENS 509832015-04-14T14:00:00014 April 2015 14:00:00
[Table view]10 CFR 35.3045(a)(1) Y-90 Microsphere Dose Less than Prescribed ENS 495422013-11-14T18:50:00014 November 2013 18:50:00 10 CFR 35.3045(a)(1) Y-90 Microshpere Dose Less than Prescribed ENS 477222011-07-05T05:00:0005 July 2011 05:00:00 10 CFR 35.3045(a)(1) Medical Event - Dosage Delivered to Patient Differed by 20% from Prescribed Dosage ENS 450342009-04-29T17:30:00029 April 2009 17:30:00 10 CFR 35.3045(a)(1) Medical Event Involving an Underdosage During Treatment for Liver Cancer ENS 436302007-09-10T15:20:00010 September 2007 15:20:00 10 CFR 35.3045(a)(1) Medical Event - Patient Received an Underdose of Yttrium-90 ENS 424532006-03-29T21:30:00029 March 2006 21:30:00 10 CFR 35.3045(a)(1) Different Length Bucket and Applicator Used During Brachytherapy Dose ENS 424692005-01-17T18:00:00017 January 2005 18:00:00 10 CFR 35.3045(a)(1) Medical Event Involving Delivered Dose Less than the Prescribed Dose 2015-04-14T14:00:00 | |