ENS 50137

v t e ENS Event
07:00 Apr 4, 2014
Title	Agreement State Report - Patient Received Less than Prescribed Dose
Event Description	The following was received from the State of Arizona via email: On May 22, 2014, the Agency was notified of a medical event that occurred on April 4, 2014 involving Y-90 labeled SIR Spheres. On April 4, 2014, an adult liver tumor patient was treated with an injection of SIR Spheres. The patient was prescribed 59.4 Gy to the liver, but instead, the actual dose to the liver was approximately 39 Gy. It was determined that the error occurred in the step of transferring the dose from the delivery vial to the dosing vial. The step of drawing up the sterile fluid was inadvertently omitted by the nuclear medicine technologist working alone which led to much less than the expected activity/sphere being transferred to the dosing vial. Only after the completion of the procedure was the large amount of residual activity detected and noted. The physicians noted that physiologic factors can affect the amount of spheres reaching the tumor so the discrepancy of the dose delivered apparently was not alarming or significant to them. The RSO discovered the medical event during a records review and recognized that the patient only received 63% of the prescribed dose. Arizona First Notice Number: 14-013

ENS 50137 +/-
Where
St Josephs Hospital And Medical Center Phoenix, Arizona (NRC Region 4)
License number:	07-024
Organization:	Arizona Radiation Regulatory Agency
Reporting

Agreement State
Time - Person (Reporting Time:+1186.32 h49.43 days <br />7.061 weeks <br />1.625 months <br />)
Opened:	Brian Goretzki 17:19 May 23, 2014
NRC Officer:	Charles Teal
Last Updated:	May 23, 2014
50137 - NRC Website
v • d • e

v t e Emergency Notification System
St Josephs Hospital And Medical Center with Agreement State
WEEKMONTHYEAR2014-04-04T07:00:00 [Table view]
[ENS list for St Josephs Hospital And Medical Center]

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