ENS 51176
ENS Event | |
|---|---|
07:00 Jun 19, 2015 | |
| Title | Agreement State Report - Medical Under Dose |
| Event Description | The following was received from the State of Washington via email:
This appears to be a medical event. Eleven Y-90 TheraSphere infusions were performed on eight patients. Five of the infusions involved the use of a smaller catheter, and for all five of these infusions the full dosage was not administered. This was determined when the nuclear medicine physician - who was the authorized user for all of the infusions - determined the percentage of dose delivered to the patient was less than 80 percent of the prescribed dose. The percentage of dose delivered calculation was performed in accordance with the procedure provided in the package insert. Waste for all five infusions was imaged using PET/CT and it was determined that a large amount of radioactive material was present at a hub in the catheter. The radiation safety officer was informed, who informed the hospital health physicist. The referring interventional radiology physicians were notified that the percentage of dose delivered was less than 80 percent, and that further investigations were underway. For these five infusions, the difference in prescribed dose and delivered dose for the organ (liver) exceeded 0.5 Sv; and the total dosage delivered differed from the prescribed dosage by 20 percent or more. The licensee is investigating this matter further and will provide a written report to the Washington State Department of Health within 15 days as required. WA Item # WA150003 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 | |
|---|---|
| University Of Washington Seattle, Washington (NRC Region 4) | |
| License number: | WN-C001-1 |
| Organization: | Washington State Dept Of Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+108.88 h4.537 days <br />0.648 weeks <br />0.149 months <br />) | |
| Opened: | Craig Lawrence 19:53 Jun 23, 2015 |
| NRC Officer: | Daniel Mills |
| Last Updated: | Jun 23, 2015 |
| 51176 - NRC Website | |
University Of Washington with Agreement State | |
WEEKMONTHYEARENS 561932022-10-25T07:00:00025 October 2022 07:00:00
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