The following report was received via e-mail:
Georgia Radioactive Materials Program (GA RMP) received a report yesterday (5/28/2014) of a medical event involving Nordion Y-90 TheraSpheres. The event occurred on 5/27/2014 at Cancer Treatment Centers of America (license #: GA 1632-1) - 600 Parkway North, Newnan GA 30265. GA RMP is tracking this under complaint number: 73962.
GA RMP was notified on 5/28/2014 by the facility's RSO. The event was discovered after treatment while verifying dose delivered to dose prescribed. At that point it was noticed that the doctor had prescribed a 20% reduction for the patient than what is considered the treatment standard. The patient received 35.31 mCi of TheraSpheres as opposed to the physician prescribed amount of 26.73 mCi. The activity delivered deviated by ~32%. The dose consequence to the tumor was 65.32 Gy as opposed to the written directive's 49.45 Gy. The tumor was located in the patient's liver. Finally, the patient was notified of the overdose by the physician.
The facility determined that the problem occurred in the treatment planning review process. The nuclear medicine technician performed the treatment plan review but verified with the standard treatment dose as opposed to the doctor prescribed dose. The facility is proposing a two person calculation sheet review for a corrective action in the future to avoid these sort of oversights. GA RMP will work with the facility to ensure these actions are sufficient to prevent reoccurrence.
It is worth mentioning that other than delivering the wrong dose, there were no complications with the procedure. No shunting issues, unintended organs dosed, equipment malfunctions, or contaminations occurred.
No outside agency notifications have been made other than this notification. GA RMP is responding at this time via telephonic investigation unless any additional doubt is raised on this event. We will follow up with more details and information to NMED as they become available.
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.