ENS Event | |
|---|---|
07:00 Nov 5, 2015 | |
| Title | Agreement State Report - Underdose to Patient |
| Event Description | The following report was received from the State of Utah via email:
On 11/5/15, a 66 year-old male patient was scheduled to receive a TheraSphere infusion. The patient required a TheraSphere vial dose of 1.94 GBq Y-90 (order was for 5.5 GBq dose calibrated on 11/1/15 to deliver 1.94 GBq on 11/5/15) to treat the left hepatic lobe of the liver to a dose of 125 Gy for hepatocellular carcinoma. It was not until the Nuclear Medicine technologist returned to the In-Patient 'hot lab' to finish her calculations and make her final measurements after the procedure that she determined that the patient received a TheraSphere vial dose of 1.502 GBq instead of the prescribed vial dose of 1.94 GBq. (22.5 percent of the dose remained in the administration system.) The Nuclear Medicine Coordinator notified the Radiation Safety Officer and the authorized user. The Authorized User notified the patient. Also, the manufacturer's representative was notified. This incident is currently under investigation. Utah Event Report No.: UT150005 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.
The State of Utah (Division of Waste Management) has received additional information, from the licensee, indicating that the actual underdose to the patient was < 5% and does not meet the reportability criteria. Therefore, this event is being retracted. Notified the R4DO (Farnholtz) and NMSS Events Notification via email. |
| Where | |
|---|---|
| Intermountain Medical Center Murray, Utah (NRC Region 4) | |
| License number: | UT 1800494 |
| Organization: | Utah Division Of Radiation Control |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+37.4 h1.558 days <br />0.223 weeks <br />0.0512 months <br />) | |
| Opened: | Mike Givens 20:24 Nov 6, 2015 |
| NRC Officer: | John Shoemaker |
| Last Updated: | Jan 26, 2016 |
| 51520 - NRC Website | |
Intermountain Medical Center with Agreement State | |
WEEKMONTHYEARENS 563302023-01-31T21:45:00031 January 2023 21:45:00
[Table view]Agreement State Liquid Radioactive Contamination ENS 515202015-11-05T07:00:0005 November 2015 07:00:00 Agreement State Agreement State Report - Underdose to Patient ENS 486992013-01-16T21:00:00016 January 2013 21:00:00 Agreement State Agreement State Report - Dose Different from Prescribed Using Yttrium-90 Therasphere Treatment ENS 476332012-02-02T07:00:0002 February 2012 07:00:00 Agreement State Agreement State Report - Dose Delivered to Wrong Patient 2023-01-31T21:45:00 | |