ENS 49815

v t e ENS Event
05:00 Jan 24, 2014
Title	Agreement State Report - Medical Event Involving Unintended Dose
Event Description	During a liver radio embolization procedure with Y-90 SIRTEX Sir-Spheres on January 24, 2014 an unanticipated shunting occurred and was identified during the procedure. The procedure for the right liver lobe was stopped when the shunting was identified. The licensee runs contrast between vial doses to verify proper delivery of the microspheres. After imaging of the patient, the licensee determined on January 27, 2014 that the unintended dose to the gastric fundus was 11 Gray. The licensee reported the medical event to ODH BRP [Ohio Department of Health - Bureau of Radiation Protection] by telephone on February 11, 2014 at 3:30pm [EST]. The referring physician and patient were notified on January 24, 2014. The patient is asymptomatic (no adverse effects) and is currently receiving medical monitoring. Ohio Report #: OH140002 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 49815 +/-
Where
Cleveland Clinic Foundation Cleveland, Ohio (NRC Region 3)
License number:	02110180013
Organization:	Ohio Bureau Of Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+444.62 h18.526 days <br />2.647 weeks <br />0.609 months <br />)
Opened:	Karl Von Ahn 17:37 Feb 11, 2014
NRC Officer:	Jeff Rotton
Last Updated:	Feb 11, 2014
49815 - NRC Website
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Cleveland Clinic Foundation with Agreement State
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