ENS Event | |
|---|---|
08:00 Feb 21, 2014 | |
| Title | Agreement State Report - Possible Medical Event with Y-90 Sir-Spheres Microspheres |
| Event Description | The following information was received by email:
On February 21, 2014 a physician in the department of Interventional Radiology (IR) at Renown Regional Medical Center in Reno, NV prescribed a patient with 26.73 mCi of Y-90 to the liver. This isotope is listed on the RAM license 16-12-0016-01 as item K, sealed sources (Sirtex Medical Limited SIR-Spheres microspheres). This case was approached in the same manner as the previous 20+ cases. The physician felt that the entire dose was appropriately delivered, therefore he went to air and flushed the catheter. The case was ended without incident. After the dose calculations were performed, it was found out that only 54.2% of the dose was delivered. The technicians investigated the delivery system and found that the majority of the undelivered isotope was in/around the 3-way stop system. The company representative [SIRTex] was [at the licensee's site] and after lengthy discussion with the physician, it is felt that the stop might have been defective. The patient and the referring physician were notified. Nevada Event: NV140006 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 | |
|---|---|
| Renown Regional Medical Center Reno, Nevada (NRC Region 4) | |
| License number: | 16-12-0016-01 |
| Organization: | Nv Div Of Rad Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+297.08 h12.378 days <br />1.768 weeks <br />0.407 months <br />) | |
| Opened: | Sneha Ravikumar 17:05 Mar 5, 2014 |
| NRC Officer: | Vince Klco |
| Last Updated: | Mar 5, 2014 |
| 49877 - NRC Website | |
Renown Regional Medical Center with Agreement State | |
WEEKMONTHYEARENS 536492018-10-05T07:00:0005 October 2018 07:00:00
[Table view]Agreement State Agreement State Report - Patient Underdose ENS 498772014-02-21T08:00:00021 February 2014 08:00:00 Agreement State Agreement State Report - Possible Medical Event with Y-90 Sir-Spheres Microspheres 2018-10-05T07:00:00 | |