ENS 51025
ENS Event | |
|---|---|
05:00 Apr 29, 2015 | |
| Title | Agreement State Report - Medical Underdose |
| Event Description | The following was received from the State of Minnesota via email:
Please note the medical event reported today to the Minnesota Department of Health Radioactive Materials Unit by Mayo Clinic in Rochester, MN. The licensee reports that on April 29, 2015, a male patient was treated with Y-90 TheraSpheres. The written directive prescribed 62.1 mCi of Y-90 (120 Gy dose). The administration proceeded as expected with the assistance of interventional radiology and nuclear medicine. As part of the procedure, the licensee uses a survey meter to survey the Y-90 microsphere vial to determine that microspheres have been administered to the patient. The procedure was described as 'uneventful' and following the initial flushing the dose rate from the vial/tubing had not decreased to zero. The physician continued with three additional flushes as part of the normal procedure. The vial/tubing dose rate did not reduce to zero. The waste material was collected and counted according the manufacturer's instructions. The licensee determined approximately 33% of the Y-90 activity was not delivered to the patient. Administered activity was estimated to be 41.85 mCi (84 Gy). Physicians anticipate no negative impact to the patient since the 'tumoricidal' dose, according to the manufacturer, is80-150 Gy, The patient has been notified. The referring physician was out of town on the day of the event and the licensee notified his fellow. The licensee is continuing with an investigation. The Minnesota Department of Health considers this investigation open and will provide more information will be as it becomes 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. |
| Where | |
|---|---|
| Mayo Clinic Rochester, Minnesota (NRC Region 3) | |
| Organization: | Minnesota Department Of Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+30.53 h1.272 days <br />0.182 weeks <br />0.0418 months <br />) | |
| Opened: | Sherrie Flaherty 11:32 Apr 30, 2015 |
| NRC Officer: | Daniel Mills |
| Last Updated: | Apr 30, 2015 |
| 51025 - NRC Website | |
Mayo Clinic with Agreement State | |
WEEKMONTHYEARENS 566712023-08-09T04:00:0009 August 2023 04:00:00
[Table view]Agreement State Lost Shipment ENS 563332022-12-16T06:00:00016 December 2022 06:00:00 Agreement State Lost Source ENS 561562022-09-28T05:00:00028 September 2022 05:00:00 Agreement State Medical Misadminstration ENS 561372022-09-27T05:00:00027 September 2022 05:00:00 Agreement State Patient Underdose ENS 560102022-07-21T05:00:00021 July 2022 05:00:00 Agreement State Medical Event ENS 553892021-07-29T05:00:00029 July 2021 05:00:00 Agreement State Ageement State Report - Medical Event ENS 552672021-05-18T05:00:00018 May 2021 05:00:00 Agreement State Patient Underdose ENS 556552020-03-17T06:00:00017 March 2020 06:00:00 Agreement State Lost Brachytherapy Seed ENS 533382018-04-13T04:00:00013 April 2018 04:00:00 Agreement State Florida Agreement State Report - Patient Received 65 Percent of Prescribed Dose to Intended Treatment Site ENS 528782017-07-28T04:00:00028 July 2017 04:00:00 Agreement State Agreement State Report - Dose Received Exceeded Prescribed Dose ENS 510252015-04-29T05:00:00029 April 2015 05:00:00 Agreement State Agreement State Report - Medical Underdose ENS 464122010-11-10T17:00:00010 November 2010 17:00:00 Agreement State Agreement State Report - Underdosage to Intended Treatment Area ENS 457882010-03-23T05:00:00023 March 2010 05:00:00 Agreement State Agreement State Report - Improper Dosage Given During Medical Treatment ENS 449492009-03-31T04:00:00031 March 2009 04:00:00 Agreement State Agreement State Report - Lost I-125 Seed 2023-08-09T04:00:00 | |