ENS 50983

From kanterella

Jump to navigation Jump to search

v t e ENS Event
14:00 Apr 14, 2015
Title	Y-90 Microsphere Dose Less than Prescribed
Event Description	A medical event involving Y-90 microspheres (TheraSpheres) occurred at approximately 1000 EDT on 4/14/15. The prescribed dosage was 34.6 mCi and the delivered dosage was 25.5 mCi. This equates to a 26.3 percent underdose. The patient was notified by the authorized user following treatment and before discharge on 4/13/15. The referring physician was notified by the authorized user via electronic mail at 1149 EDT on 4/13/15. The initial hypothesis on cause may have been related to difficult access to an anatomical region in the liver, resulting in the need to use lower than normal pressure on the syringe used for microsphere delivery. All established administration procedures were followed. A written report to the appropriate NRC offices will follow within 15 days. * * RETRACTION FROM MACK RICHARD TO VINCE KLCO ON 4/14/15 AT 1515 EDT * * * The following information was excerpted from the licensee email: The reason for this retraction is based upon discussions with the Authorized User [AU] who performed the Y-90 treatment and additional questions raised and clarifications made by the NRC Region III Office. During that discussion, the AU indicated that he utilized a lower syringe pressure than normal to prevent reflux of the Y-90 microspheres which would have resulted in a less than optimal treatment. The AU acknowledged that the amount administered was acceptable, given the need to use the lower syringe pressure and that he will modify the written directive to appropriately reflect a change in the written directive based upon those circumstances. Notified the R3DO (McCraw) and NMSS Events Notification via email. 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 50983 +/- *RETRACTED*
Where
Indiana University Medical Center Indianapolis, Indiana (NRC Region 3)
License number:	13-02752-03
Organization:	Indiana University Medical Center
Reporting

10 CFR 35.3045(a)(1)
Time - Person (Reporting Time:+-2.27 h-0.0946 days <br />-0.0135 weeks <br />-0.00311 months <br />)
Opened:	Mack Richards 11:44 Apr 14, 2015
NRC Officer:	Vince Klco
Last Updated:	Apr 14, 2015
50983 - NRC Website
v • d • e

v t e Emergency Notification System
Indiana University Medical Center with 10 CFR 35.3045(a)(1)
WEEKMONTHYEAR2015-04-14T14:00:00 [Table view]
[ENS list for Indiana University Medical Center]

Retrieved from "https://kanterella.com/w/index.php?title=ENS_50983&oldid=421636"

ENS Notification