ENS 51118
ENS Event | |
|---|---|
05:00 Jun 2, 2015 | |
| Title | Agreement State Report - Medical Event Due to Mis-Administration of Y-90 Sir-Spheres |
| Event Description | The following information was received via E-mail:
The Director of Radiology at Riverside Medical Center, Kankakee, IL called the Agency [Illinois Emergency Management Agency] to advise that a medical event had occurred during the administration of a Y-90 SIR-Sphere treatment on the morning of June 2, 2015. 35.2 mCi of Y-90 was intended to be delivered to the patient's liver to treat metastatic cancer lesions via the hepatic artery. However, when the patient was imaged immediately following the treatment, the kidney was observed as the organ which had received the dose with no material evident in the liver. It was determined that the infusion catheter was improperly placed. Instead of placement in the patient's hepatic artery, the renal artery was the infusion site. This was the facility's first patient to undergo this treatment modality. As a result, the manufacturer's proctor was present in addition to the treatment team members which included the radiologist, the radiation safety officer, the nuclear medicine technologist as well as others. The radiologist immediately informed the patient of the error while he was in post-op. As the facility had a second dose of Y-90 on hand of the same amount, and the patient consented, a second attempt was made that same afternoon where the infusion went as expected and the intended dose was delivered as originally planned to the liver with no complications. Although normally, an outpatient procedure, the patient was held overnight. Universal precautions were implemented throughout the time period and although the patient's sweat and saliva were not sources of contamination, the hospital managed the patient as they would an I-131 therapy patient and routine collection and measurement of the patient's urine was performed before discharge to the sewer system.. Radioactivity was confirmed as present in the urine when measured with a Geiger counter near the surface of the container. No other contamination was noted in the room. The patient was discharged the next day and follow up appointments are pending with the radiologist as well as a urologist. Dose estimates to the patient's kidney as a result of the event are being performed by the manufacturer as well as the medical center's consultant. The Agency is investigating this event and the licensee has been advised that a written report must be submitted per regulation. Illinois Item Number: IL15013 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 | |
|---|---|
| Riverside Medical Center Kankakee, Illinois (NRC Region 3) | |
| License number: | IL-01242-01 |
| Organization: | Illinois Emergency Mgmt. Agency |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+55.47 h2.311 days <br />0.33 weeks <br />0.076 months <br />) | |
| Opened: | Daren Perrero 12:28 Jun 4, 2015 |
| NRC Officer: | Donald Norwood |
| Last Updated: | Jun 4, 2015 |
| 51118 - NRC Website | |
Riverside Medical Center with Agreement State | |
WEEKMONTHYEARENS 538622016-04-20T06:00:00020 April 2016 06:00:00
[Table view]Agreement State Agreement State Report - Underdose Exceeding 20 Percent of the Prescribed Dose ENS 511182015-06-02T05:00:0002 June 2015 05:00:00 Agreement State Agreement State Report - Medical Event Due to Mis-Administration of Y-90 Sir-Spheres ENS 460982010-07-13T05:00:00013 July 2010 05:00:00 Agreement State Agreement State Report - Missing Brachytherapy Sources 2016-04-20T06:00:00 | |