ENS Event | |
|---|---|
04:00 Feb 27, 2014 | |
| Title | |
| Event Description | The following was received from New York City Bureau of Rad Health via email:
[A] patient was receiving treatment of left lobe of liver with Y-90 Sir Spheres. Half way through the procedure the catheter became clogged. 30 mCi of Y-90 was prescribed, only 22.5 mCi was delivered. 7.5 mCi remained in the catheter. [The] initial report stated that treatment of right lobe of liver had been scheduled for April. [The] initial report stated that Physician decided to treat left lobe of liver with makeup dose of 7.5 mCi Y-90 at that time. [The] ORH [Office of Radiological Health] inspector stated that multiple attempts were made to flush the catheter without success. The catheter was removed and the remainder of the dose was administered at the date of the initial clog with a micro-catheter. [The] physician spoke to the vendor rep (company SureFire). [The] company stated that cause of the clog would be investigated when the Y-90 had decayed. [The] referring physician was notified. [This] incident is considered a reportable medical event because the administered dose differed from the prescribed dose by >20%. [The] hospital states that if any future incidents such as this equipment malfunction occurs, they will keep the patient in treatment position to determine by measurement if proper dosage was delivered. If measurements indicate that inadequate dosage was delivered, they will draw another dose to supplement the original administration until the appropriate dose is administered to the patient. 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: | 75-2885 |
| Organization: | New York City Bureau Of Rad Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+273.35 h11.39 days <br />1.627 weeks <br />0.374 months <br />) | |
| Opened: | Tobias Lickerman 12:21 Mar 10, 2014 |
| NRC Officer: | Charles Teal |
| Last Updated: | Mar 10, 2014 |
| 49887 - 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 | |